Provider Demographics
NPI:1528469772
Name:CHANGE ACADEMY LAKE OZARK
Entity type:Organization
Organization Name:CHANGE ACADEMY LAKE OZARK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OTR/L
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGEMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-552-8007
Mailing Address - Street 1:130 CALO LN
Mailing Address - Street 2:
Mailing Address - City:LAKE OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65049-9208
Mailing Address - Country:US
Mailing Address - Phone:573-365-2221
Mailing Address - Fax:573-365-2224
Practice Address - Street 1:130 CALO LN
Practice Address - Street 2:
Practice Address - City:LAKE OZARK
Practice Address - State:MO
Practice Address - Zip Code:65049-9208
Practice Address - Country:US
Practice Address - Phone:573-365-2221
Practice Address - Fax:573-365-2224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-08
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO016604251E00000X, 252Y00000X, 305R00000X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No251E00000XAgenciesHome Health
No252Y00000XAgenciesEarly Intervention Provider Agency
No305R00000XManaged Care OrganizationsPreferred Provider Organization