Provider Demographics
NPI:1124841101
Name:TIME 4 CHANGE
Entity type:Organization
Organization Name:TIME 4 CHANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:CHARESE
Authorized Official - Last Name:WICKS
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:662-629-0516
Mailing Address - Street 1:84 TRIBBLE RD
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:38635-8600
Mailing Address - Country:US
Mailing Address - Phone:662-629-0516
Mailing Address - Fax:
Practice Address - Street 1:66 TRIBBLE RD
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:38635-8600
Practice Address - Country:US
Practice Address - Phone:662-629-0516
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-06
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)