Provider Demographics
NPI:1902280126
Name:EAST ALABAMA CENTER FOR CHANGE, LLC
Entity Type:Organization
Organization Name:EAST ALABAMA CENTER FOR CHANGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:334-734-2603
Mailing Address - Street 1:124 BRAGG AVE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:AL
Mailing Address - Zip Code:36830-3809
Mailing Address - Country:US
Mailing Address - Phone:334-734-2603
Mailing Address - Fax:334-887-0031
Practice Address - Street 1:124 BRAGG AVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:AL
Practice Address - Zip Code:36830-3809
Practice Address - Country:US
Practice Address - Phone:334-734-2603
Practice Address - Fax:334-887-0031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALAL1749103TC0700X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL102I626774OtherMEDICARE PTAN