Provider Demographics
NPI:1699063297
Name:AFFECTING CHANGE, LLC
Entity type:Organization
Organization Name:AFFECTING CHANGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:D
Authorized Official - Last Name:CHARLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:313-587-9869
Mailing Address - Street 1:22511 TELEGRAPH RD STE 128
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-4130
Mailing Address - Country:US
Mailing Address - Phone:248-905-1126
Mailing Address - Fax:313-209-8989
Practice Address - Street 1:22511 TELEGRAPH RD STE 128
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-4130
Practice Address - Country:US
Practice Address - Phone:248-905-1126
Practice Address - Fax:313-209-8989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-16
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MID25724251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty