Provider Demographics
NPI:1144971342
Name:AUTHENTIC CHANGE PSYCHOTHERAPY, INC.
Entity type:Organization
Organization Name:AUTHENTIC CHANGE PSYCHOTHERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:401-489-6885
Mailing Address - Street 1:133 GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-5905
Mailing Address - Country:US
Mailing Address - Phone:401-489-6885
Mailing Address - Fax:
Practice Address - Street 1:154 WATERMAN ST.
Practice Address - Street 2:SUITE 15, 3RD FLOOR
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906
Practice Address - Country:US
Practice Address - Phone:401-489-6885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-10
Last Update Date:2022-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty