| Name: | East Alabama Center for Change, LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Exists |
| Date of registration: | 13 Nov 2014 (10 years ago) (Companies founded in November 2014) |
| Entity Number: | 000-322-504 |
| Register Number: | 000322504 |
| ZIP code: | 36830 (Companies in Lee, 36830) |
| County: | Lee |
| Place of Formation: | Lee County |
| Principal Address: | 124 BRAGG AVEAUBURN, AL 36830 |
| Registered Office Street Address: | 2006 KEYSTONE DRIVEAUBURN, AL 36830 |
Activities
PRIVATE PRACTICE CLINICAL PSYCHOLOGY
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1902280126 | 2015-07-17 | 2015-07-17 | 124 BRAGG AVE, AUBURN, AL, 368303809, US | 124 BRAGG AVE, AUBURN, AL, 368303809, US | |||||||||||||||||||||||||||||||||
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| Phone | +1 334-734-2603 |
| Fax | 3348870031 |
Authorized person
| Name | AMBER ELIZABETH DOUGLAS |
| Role | LICENSED PSYCHOLOGIST |
| Phone | 3347342603 |
Taxonomy
| Taxonomy Code | 103TC0700X - Clinical Psychologist |
| License Number | AL1749 |
| State | AL |
| Is Primary | Yes |
| Taxonomy Code | 103TH0004X - Health Psychologist |
| License Number | AL1749 |
| State | AL |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICARE PTAN |
| Number | 102I626774 |
| State | AL |
| Name | Role | Address |
|---|---|---|
| DOUGLAS, AMBER E | Agent | 124 BRAGG AVEAUBURN, AL 36830 |
| Name | Role | Address |
|---|---|---|
| DOUGLAS, AMBER E | Organizer | 124 BRAGG AVEAUBURN, AL 36830 |
Date of last update: 03 Aug 2024
Sources: Alabama Secretary of State
