Provider Demographics
NPI:1487977583
Name:CHANGING HOW I LIVE LIFE
Entity type:Organization
Organization Name:CHANGING HOW I LIVE LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:D
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCDC
Authorized Official - Phone:512-385-4799
Mailing Address - Street 1:1006 E. YAGER LANE
Mailing Address - Street 2:A 104
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78753
Mailing Address - Country:US
Mailing Address - Phone:512-385-4799
Mailing Address - Fax:
Practice Address - Street 1:1006 E YAGER LN
Practice Address - Street 2:A 104
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78753-7088
Practice Address - Country:US
Practice Address - Phone:512-385-4799
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-04
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 251C00000X, 253Z00000X
TX5006253Z00000X
TX101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No251B00000XAgenciesCase ManagementGroup - Single Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX065483201Medicaid