Provider Demographics
NPI:1336815273
Name:THE LIFE CHANGE GROUP NC
Entity Type:Organization
Organization Name:THE LIFE CHANGE GROUP NC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER AND MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-512-6945
Mailing Address - Street 1:2215 US 52 N
Mailing Address - Street 2:
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28001-9510
Mailing Address - Country:US
Mailing Address - Phone:980-354-4222
Mailing Address - Fax:
Practice Address - Street 1:2215 US 52 N
Practice Address - Street 2:
Practice Address - City:ALBEMARLE
Practice Address - State:NC
Practice Address - Zip Code:28001-9510
Practice Address - Country:US
Practice Address - Phone:980-354-4222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health