Provider Demographics
NPI:1285803072
Name:COUNSELING FOR A CHANGE
Entity type:Organization
Organization Name:COUNSELING FOR A CHANGE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:SELOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MS,CADC,LCPC
Authorized Official - Phone:618-889-3987
Mailing Address - Street 1:70 SANDY PT
Mailing Address - Street 2:
Mailing Address - City:GOREVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62939-3122
Mailing Address - Country:US
Mailing Address - Phone:618-889-3987
Mailing Address - Fax:618-351-1419
Practice Address - Street 1:70 SANDY PT
Practice Address - Street 2:
Practice Address - City:GOREVILLE
Practice Address - State:IL
Practice Address - Zip Code:62939-3122
Practice Address - Country:US
Practice Address - Phone:618-889-3987
Practice Address - Fax:618-351-1419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180006639101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180006639OtherSTATE LICENSE, LCPC
IL11826508OtherCAQH
IL03932079OtherBLUE CROSS BLUE SHIELD