Provider Demographics
NPI:1912262676
Name:CHANGING DESTINY BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:CHANGING DESTINY BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMIKO
Authorized Official - Middle Name:L
Authorized Official - Last Name:PURDIE
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:702-234-3141
Mailing Address - Street 1:PO BOX 91693
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89009-1693
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:784 VORTEX AVE
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89002-6545
Practice Address - Country:US
Practice Address - Phone:702-234-3141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health