NPIMap

Organization Active NPI

Indelible Changes LLC

  • Mental Health Counselor
  • Woodbridge, VA
National Provider Identifier
1720540107
Registry record updated Dec 14, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Mental Health CounselorTaxonomy code 101YM0800X
Legal business name
INDELIBLE CHANGES LLC
Practice address
12890 Harbor Dr
Woodbridge, VA 22192-2921
Phone
(570) 316-1020
NPI assigned
Apr 3, 2019
Last updated
Dec 14, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 14, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Nicholas Antonio Williams, LPCNPI 1720338627
Title
Ceo
Phone
(703) 474-0585

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 9

Specialty (taxonomy)CodeLicenseStatePrimary
Counselor 101Y00000X NU
Mental Health Counselor 101YM0800X NU Primary
Psychologist 103T00000X NU
Social Worker 104100000X NU
Clinical Social Worker 1041C0700X NU
Marriage & Family Therapist 106H00000X NU
Mental Health Clinic/Center (Including Community Mental Health Center) 261QM0801X NU
Adult Mental Health Clinic/Center 261QM0850X NU
Adolescent and Children Mental Health Clinic/Center 261QM0855X NU

Addresses

Primary practice location

12890 Harbor Dr
Woodbridge, VA 22192-2921

Mailing address

4191 Waterway Dr
Dumfries, VA 22025-1602
Phone (703) 474-0585

Other identifiers 1

IdentifierTypeStateIssuer
575326118MedicaidVA

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address nicholas.williams@indeliblechanges.org

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in VA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20240415004072 VA Part B Supplier - Clinic/Group Practice 9234578808 Receives reassigned benefits from 4 practitioners
Practice locations: Woodbridge, VA

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1554249600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1670976000000",
    "number": "1720540107",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4191 WATERWAY DR",
            "city": "DUMFRIES",
            "state": "VA",
            "postal_code": "220251602",
            "telephone_number": "703-474-0585"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12890 HARBOR DR",
            "city": "WOODBRIDGE",
            "state": "VA",
            "postal_code": "221922921",
            "telephone_number": "570-316-1020"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INDELIBLE CHANGES LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-04-03",
        "last_updated": "2022-12-14",
        "certification_date": "2022-12-14",
        "status": "A",
        "authorized_official_last_name": "WILLIAMS",
        "authorized_official_first_name": "NICHOLAS",
        "authorized_official_middle_name": "ANTONIO",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "703-474-0585",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "LPC"
    },
    "taxonomies": [
        {
            "code": "101Y00000X",
            "taxonomy_group": "",
            "desc": "Counselor",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "103T00000X",
            "taxonomy_group": "",
            "desc": "Psychologist",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "104100000X",
            "taxonomy_group": "",
            "desc": "Social Worker",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "106H00000X",
            "taxonomy_group": "",
            "desc": "Marriage & Family Therapist",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QM0850X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adult Mental Health",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QM0855X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adolescent and Children Mental Health",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "575326118",
            "state": "VA"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "nicholas.williams@indeliblechanges.org",
            "affiliation": "N",
            "address_1": "12890 Harbor Dr",
            "city": "Woodbridge",
            "state": "VA",
            "country_code": "US",
            "postal_code": "221922921",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Woodbridge, VA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 14, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.