Provider Demographics
NPI:1447098959
Name:CHANGE ACADEMY AT LAKE OF THE OZARKS
Entity type:Organization
Organization Name:CHANGE ACADEMY AT LAKE OF THE OZARKS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF REVENUE CYCLE MANAGEMENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-829-4060
Mailing Address - Street 1:5500 MING AVE STE 410
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93309-4631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7809 SCHELHORN RD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306-2825
Practice Address - Country:US
Practice Address - Phone:571-489-4879
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHANGE ACADEMY AT LAKE OF THE OZARKS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility