Provider Demographics
NPI:1780122713
Name:CHANGE TALK LLC
Entity type:Organization
Organization Name:CHANGE TALK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:860-638-9169
Mailing Address - Street 1:251 ESSEX PLAZA
Mailing Address - Street 2:
Mailing Address - City:ESSEX
Mailing Address - State:CT
Mailing Address - Zip Code:06426
Mailing Address - Country:US
Mailing Address - Phone:860-638-9169
Mailing Address - Fax:860-469-2938
Practice Address - Street 1:251 ESSEX PLAZA
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:CT
Practice Address - Zip Code:06426
Practice Address - Country:US
Practice Address - Phone:860-638-9169
Practice Address - Fax:860-469-2938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-10
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003050101YM0800X
101YM0800X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008071044Medicaid