Provider Demographics
NPI:1184081564
Name:INNER CHANGELLC, COUNSELING AND EDUCATION CENTER
Entity type:Organization
Organization Name:INNER CHANGELLC, COUNSELING AND EDUCATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:SHERRI
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:GATSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:404-989-3114
Mailing Address - Street 1:3600 DEKALB TECHNOLOGY PKWY
Mailing Address - Street 2:SUITE140
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30340-3612
Mailing Address - Country:US
Mailing Address - Phone:404-989-3114
Mailing Address - Fax:470-282-5102
Practice Address - Street 1:3600 DEKALB TECHNOLOGY PKWY
Practice Address - Street 2:SUITE140
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30340-3612
Practice Address - Country:US
Practice Address - Phone:404-989-3114
Practice Address - Fax:470-282-5102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-15
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0019811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003136433AMedicaid
GA003136433AMedicaid