Provider Demographics
NPI:1205552031
Name:INDIVIDUAL AND FAMILY COUNSELING CLINIC FOR HEALING AND CHANGE
Entity type:Organization
Organization Name:INDIVIDUAL AND FAMILY COUNSELING CLINIC FOR HEALING AND CHANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:LINDSAY
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNER
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:209-406-0445
Mailing Address - Street 1:9854 NEW HOPE RD
Mailing Address - Street 2:
Mailing Address - City:GALT
Mailing Address - State:CA
Mailing Address - Zip Code:95632-8807
Mailing Address - Country:US
Mailing Address - Phone:209-406-0445
Mailing Address - Fax:
Practice Address - Street 1:3120 O ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-6519
Practice Address - Country:US
Practice Address - Phone:209-406-0445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-13
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1679843270Medicaid