Provider Demographics
NPI:1184023970
Name:THE INITIATIVE FOR CHANGE AND DEVELOPMENT
Entity type:Organization
Organization Name:THE INITIATIVE FOR CHANGE AND DEVELOPMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKSHEAR
Authorized Official - Suffix:
Authorized Official - Credentials:LCDC, CART, COPSD
Authorized Official - Phone:832-964-3849
Mailing Address - Street 1:1146 WILLOW CREEK DRIVE
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:TX
Mailing Address - Zip Code:77571
Mailing Address - Country:US
Mailing Address - Phone:832-964-3849
Mailing Address - Fax:
Practice Address - Street 1:1146 WILLOW CREEK DR
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:TX
Practice Address - Zip Code:77571-2711
Practice Address - Country:US
Practice Address - Phone:832-964-3849
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-18
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11387251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health