Provider Demographics
NPI:1154625424
Name:FLYING CHANGE
Entity type:Organization
Organization Name:FLYING CHANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LISSA
Authorized Official - Middle Name:B
Authorized Official - Last Name:CORCORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-512-0834
Mailing Address - Street 1:4680 POLO LN SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-5346
Mailing Address - Country:US
Mailing Address - Phone:404-512-0834
Mailing Address - Fax:770-832-3969
Practice Address - Street 1:4680 POLO LN SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-5346
Practice Address - Country:US
Practice Address - Phone:404-512-0834
Practice Address - Fax:770-832-3969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-30
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty