Provider Demographics
NPI:1700469970
Name:THE CHANGE MOVEMENT A MARRIAGE AND FAMILY THERAPY CORPORATION
Entity type:Organization
Organization Name:THE CHANGE MOVEMENT A MARRIAGE AND FAMILY THERAPY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:RENARD
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:310-908-4598
Mailing Address - Street 1:22287 MULHOLLAND HWY # 552
Mailing Address - Street 2:
Mailing Address - City:CALABASAS
Mailing Address - State:CA
Mailing Address - Zip Code:91302-5157
Mailing Address - Country:US
Mailing Address - Phone:747-474-2325
Mailing Address - Fax:
Practice Address - Street 1:2001 S BARRINGTON AVE STE 203
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-5385
Practice Address - Country:US
Practice Address - Phone:747-474-2325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1356476089OtherA RENARD CARTER LMFT
CA1356476089OtherALFRED R CARTER LMFT