Organization
CENTER OF CHANGE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
SUZANNE MCKENNA PHD (CO-OWNER)
(417) 888-0886
Entity
Organization
Contact information
Practice address
1615A S INGRAM MILL RD, SPRINGFIELD, MO 65804-2261
(417) 888-0886
(417) 888-0846
Mailing address
1615A S INGRAM MILL RD, SPRINGFIELD, MO 65804-2261
(417) 888-0886
(417) 888-0846
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
PY01825
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
508440609
—
MO
Enumeration date
02/18/2008
Last updated
05/01/2008
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