Provider Demographics
NPI:1215068069
Name:OPEN DOOR CENTER FOR CHANGE LLC
Entity type:Organization
Organization Name:OPEN DOOR CENTER FOR CHANGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MOSHER-GARVEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, CSAC
Authorized Official - Phone:608-827-7220
Mailing Address - Street 1:6502 GRAND TETON PLZ STE 102
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-1047
Mailing Address - Country:US
Mailing Address - Phone:608-827-7220
Mailing Address - Fax:608-827-7223
Practice Address - Street 1:6502 GRAND TETON PLZ STE 102
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1047
Practice Address - Country:US
Practice Address - Phone:608-827-7220
Practice Address - Fax:608-827-7223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2024-03-07
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
WI42198900Medicaid
WI42198900Medicaid
WI000084515Medicare UPIN