Provider Demographics
NPI:1154965150
Name:POSITIVE CHANGE THERAPY, PLLC
Entity type:Organization
Organization Name:POSITIVE CHANGE THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BYERS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:203-651-9255
Mailing Address - Street 1:345 PAYNE DR
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-1752
Mailing Address - Country:US
Mailing Address - Phone:860-651-9255
Mailing Address - Fax:
Practice Address - Street 1:422 HIGHLAND AVE STE 5
Practice Address - Street 2:
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410-2526
Practice Address - Country:US
Practice Address - Phone:203-651-9255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-01
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004025193Medicaid