Provider Demographics
NPI:1285311753
Name:WINGS OF CHANGE LLC
Entity type:Organization
Organization Name:WINGS OF CHANGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SERGIUSZ
Authorized Official - Middle Name:PIOKR
Authorized Official - Last Name:JOSKOW
Authorized Official - Suffix:II
Authorized Official - Credentials:LCSW
Authorized Official - Phone:207-313-9798
Mailing Address - Street 1:WINGS OF CHANGE LLC 927 SHERRY DR
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:927 SHERRY DR
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501
Practice Address - Country:US
Practice Address - Phone:207-313-9798
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty