Basic Information
| Provider Information | |||||||||
| NPI: | 1821586843 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COURAGE TO CHANGE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 HIGHLAND AVE STE C | ||||||||
| Address2: | |||||||||
| City: | HADDON TOWNSHIP | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081082634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568543155 | ||||||||
| FaxNumber: | 8568540992 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 HIGHLAND AVE STE C | ||||||||
| Address2: | |||||||||
| City: | HADDON TOWNSHIP | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081082634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568543155 | ||||||||
| FaxNumber: | 8568540992 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2018 | ||||||||
| LastUpdateDate: | 04/25/2018 | ||||||||
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| AuthorizedOfficialLastName: | BAKEY | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/SOLE MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 8568543155 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LPC, LCADC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 37LC00182400 | NJ | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 37PC00457200 | NJ | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.