Provider Demographics
NPI:1902135692
Name:CHANGE AND DEVELOPMENT INSTITUTE, LLC
Entity Type:Organization
Organization Name:CHANGE AND DEVELOPMENT INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:314-680-8179
Mailing Address - Street 1:8123 JANUARY AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63134-1513
Mailing Address - Country:US
Mailing Address - Phone:314-680-8179
Mailing Address - Fax:
Practice Address - Street 1:8123 JANUARY AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63134-1513
Practice Address - Country:US
Practice Address - Phone:314-680-8179
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-09
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007036005101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty