Provider Demographics
NPI:1750760492
Name:VISUALIZE CHANGE, LLC
Entity type:Organization
Organization Name:VISUALIZE CHANGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FACILITY OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:WETZEL
Authorized Official - Suffix:
Authorized Official - Credentials:MS LPC NCC CCTP
Authorized Official - Phone:570-875-3333
Mailing Address - Street 1:913 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:PA
Mailing Address - Zip Code:17921-1243
Mailing Address - Country:US
Mailing Address - Phone:570-875-3333
Mailing Address - Fax:570-875-3433
Practice Address - Street 1:913 CENTRE ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:PA
Practice Address - Zip Code:17921-1243
Practice Address - Country:US
Practice Address - Phone:570-875-3333
Practice Address - Fax:570-875-3433
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-05-27
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA547030251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1030502410001Medicaid