Basic Information
| Provider Information | |||||||||
| NPI: | 1891465456 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHANGING LIVES REHABILITATION HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHANGING LIVES WELLNESS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 122 NUTMEG DR | ||||||||
| Address2: | |||||||||
| City: | RUSTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712700101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184584798 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 122 NUTMEG DR | ||||||||
| Address2: | |||||||||
| City: | RUSTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712700101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184584798 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2021 | ||||||||
| LastUpdateDate: | 09/28/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | WHITNEY | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3184584798 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 251S00000X | N | Agencies | Community/Behavioral Health | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.