Provider Demographics
NPI:1902107428
Name:LIFE CHANGES, LLC
Entity Type:Organization
Organization Name:LIFE CHANGES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:BROOKS
Authorized Official - Last Name:DEGLING
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:860-944-1171
Mailing Address - Street 1:147 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EAST BERLIN
Mailing Address - State:CT
Mailing Address - Zip Code:06023-1136
Mailing Address - Country:US
Mailing Address - Phone:860-944-1171
Mailing Address - Fax:860-829-1550
Practice Address - Street 1:193 MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3423
Practice Address - Country:US
Practice Address - Phone:860-944-1171
Practice Address - Fax:860-829-1550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-15
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001763101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty