Provider Demographics
NPI:1700132131
Name:SEACHANGE OVERALL WELLNESS, PLLC
Entity type:Organization
Organization Name:SEACHANGE OVERALL WELLNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:BUCK
Authorized Official - Suffix:
Authorized Official - Credentials:DBH, LPC
Authorized Official - Phone:480-510-8502
Mailing Address - Street 1:14256 S 47TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-6205
Mailing Address - Country:US
Mailing Address - Phone:480-510-8502
Mailing Address - Fax:
Practice Address - Street 1:14256 S 47TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-6205
Practice Address - Country:US
Practice Address - Phone:480-510-8502
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-03
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-13746251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health