Provider Demographics
NPI:1073108254
Name:CHANGE AZ
Entity type:Organization
Organization Name:CHANGE AZ
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:C
Authorized Official - Last Name:RUELAZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LPC
Authorized Official - Phone:623-632-9586
Mailing Address - Street 1:6692 E VIA JARDIN VERDE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85756-0022
Mailing Address - Country:US
Mailing Address - Phone:520-276-6893
Mailing Address - Fax:
Practice Address - Street 1:6692 E VIA JARDIN VERDE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85756-0022
Practice Address - Country:US
Practice Address - Phone:520-276-6893
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-09
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)