Provider Demographics
NPI:1720511330
Name:CENTER FOR CHANGE, LLC
Entity Type:Organization
Organization Name:CENTER FOR CHANGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:262-607-2770
Mailing Address - Street 1:196 MARTIN ST
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:WI
Mailing Address - Zip Code:53585-9769
Mailing Address - Country:US
Mailing Address - Phone:262-607-2770
Mailing Address - Fax:
Practice Address - Street 1:93 W GENEVA ST
Practice Address - Street 2:SUITE 2E
Practice Address - City:WILLIAMS BAY
Practice Address - State:WI
Practice Address - Zip Code:53191-9518
Practice Address - Country:US
Practice Address - Phone:262-607-2770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5479-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100054731Medicaid