| Indelible Changes Llc | |
|
12890 Harbor Dr Woodbridge VA 22192-2921 | |
| (570) 316-1020 | |
| Not Available |
| Full Name | Indelible Changes Llc |
|---|---|
| Speciality | Counselor |
| Location | 12890 Harbor Dr, Woodbridge, Virginia |
| Authorized Official Name and Position | Nicholas Antonio Williams (CEO) |
| Authorized Official Contact | 7034740585 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Indelible Changes Llc 4191 Waterway Dr Dumfries VA 22025-1602 Ph: (703) 474-0585 | Indelible Changes Llc 12890 Harbor Dr Woodbridge VA 22192-2921 Ph: (570) 316-1020 |
| NPI Number | 1720540107 |
|---|---|
| Provider Enumeration Date | 04/03/2019 |
| Last Update Date | 12/14/2022 |
| Certification Date | 12/14/2022 |
| Medicare PECOS PAC ID | 9234578808 |
|---|---|
| Medicare Enrollment ID | O20240415004072 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1720540107 | NPI | - | NPPES |
| 575326118 | Medicaid | VA |
| Provider Name | Nicholas Antonio Williams |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1720338627 PECOS PAC ID: 7517297161 Enrollment ID: I20240415004076 |
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