Provider Demographics
NPI:1548868730
Name:DYNAMIC CHANGE
Entity type:Organization
Organization Name:DYNAMIC CHANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:CANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, CRC
Authorized Official - Phone:470-347-6896
Mailing Address - Street 1:1102 WESTCHASE LN SW APT 910
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30336-4427
Mailing Address - Country:US
Mailing Address - Phone:404-274-7408
Mailing Address - Fax:
Practice Address - Street 1:2255 CUMBERLAND PKWY SE STE 240
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-4515
Practice Address - Country:US
Practice Address - Phone:470-347-6896
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-11
Last Update Date:2020-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty