Provider Demographics
NPI:1427354729
Name:MIDCITIES CENTER FOR CHANGE, LLC
Entity type:Organization
Organization Name:MIDCITIES CENTER FOR CHANGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:ALVIN
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:JR
Authorized Official - Credentials:LCSW, CART
Authorized Official - Phone:817-917-2335
Mailing Address - Street 1:610 S INDUSTRIAL BLVD
Mailing Address - Street 2:SUITE 307
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76040-5048
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:610 S INDUSTRIAL BLVD
Practice Address - Street 2:SUITE 307
Practice Address - City:EULESS
Practice Address - State:TX
Practice Address - Zip Code:76040-5048
Practice Address - Country:US
Practice Address - Phone:817-917-2335
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-03
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50547251S00000X
TX65300251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health