Provider Demographics
NPI:1124322284
Name:POWER FOR CHANGE, LLC
Entity type:Organization
Organization Name:POWER FOR CHANGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:SHEFCHIK
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC, NCC
Authorized Official - Phone:920-770-4088
Mailing Address - Street 1:123 N OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-2831
Mailing Address - Country:US
Mailing Address - Phone:920-770-4088
Mailing Address - Fax:651-705-0026
Practice Address - Street 1:123 N OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-2831
Practice Address - Country:US
Practice Address - Phone:920-770-4088
Practice Address - Fax:920-496-7922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-04
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100013205Medicaid