Provider Demographics
NPI:1770916587
Name:COLLABORATIVE CHANGE LLC
Entity type:Organization
Organization Name:COLLABORATIVE CHANGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BABE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:317-225-9483
Mailing Address - Street 1:8331 CRAWFORDSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46234-7740
Mailing Address - Country:US
Mailing Address - Phone:317-296-4187
Mailing Address - Fax:
Practice Address - Street 1:1060 E MAIN ST # S401
Practice Address - Street 2:
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-1408
Practice Address - Country:US
Practice Address - Phone:317-296-4187
Practice Address - Fax:317-203-0995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-15
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005850A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN20119194AMedicaid