Provider Demographics
NPI:1720526387
Name:A CHANGE OF MIND, LLC
Entity Type:Organization
Organization Name:A CHANGE OF MIND, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:239-260-4387
Mailing Address - Street 1:5020 TAMIAMI TRAIL N
Mailing Address - Street 2:SUITE 202
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34103
Mailing Address - Country:US
Mailing Address - Phone:239-260-4387
Mailing Address - Fax:844-715-9627
Practice Address - Street 1:5020 TAMIAMI TRAIL N
Practice Address - Street 2:SUITE 202
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34103
Practice Address - Country:US
Practice Address - Phone:239-260-4387
Practice Address - Fax:844-715-9627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-03
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW92931041C0700X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty