Provider Demographics
NPI:1891130084
Name:POSITIVE CHANGE COUNSELING AGENCY
Entity type:Organization
Organization Name:POSITIVE CHANGE COUNSELING AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTY
Authorized Official - Middle Name:TYRONE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:318-779-8527
Mailing Address - Street 1:348 W 79TH ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-4820
Mailing Address - Country:US
Mailing Address - Phone:318-688-8190
Mailing Address - Fax:318-688-8193
Practice Address - Street 1:351 W 79TH ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-4819
Practice Address - Country:US
Practice Address - Phone:318-688-8190
Practice Address - Fax:318-688-8193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-01
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health