Provider Demographics
NPI:1295250207
Name:LIFECHANGE PSYCHOLOGICAL SERVICES, LLC
Entity type:Organization
Organization Name:LIFECHANGE PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHUCK
Authorized Official - Middle Name:
Authorized Official - Last Name:EDGINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:405-315-5756
Mailing Address - Street 1:3612 LEA CT
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-8127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4117 NW 122ND ST STE A1
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8819
Practice Address - Country:US
Practice Address - Phone:405-562-9260
Practice Address - Fax:405-260-9559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-10
Last Update Date:2021-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1088103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200254090AMedicaid