| 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 |
| Provider Name | Joshua F Sloan |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1790574317 PECOS PAC ID: 1658883947 Enrollment ID: I20250623002988 |
| Provider Name | Sheila Williams |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1558252726 PECOS PAC ID: 8022506831 Enrollment ID: I20251023001587 |
| Provider Name | Joanne Perdu Ouimet |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1023622230 PECOS PAC ID: 3476029554 Enrollment ID: I20260416000974 |
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