MEDICARE: FAMILIES 4 CHANGE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	000480	GA

General Provider Information

NPI Number	:	1134544117
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILIES 4 CHANGE, INC.

Provider Business Mailing Address
First Line	:	1551 JENNINGS MILL RD
Second Line	:	SUITE 3100B
City	:	BOGART
State	:	GA
Zip	:	30622-2544
Country	:	US
Telephone Number	:	706-369-9707
Fax Number	:	706-369-9708

Provider Business Practice Location Address
First Line	:	1551 JENNINGS MILL RD
Second Line	:	SUITE 3100B
City	:	BOGART
State	:	GA
Zip	:	30622-2544
Country	:	US
Telephone Number	:	706-369-9707
Fax Number	:	706-369-9708

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DR. WILLIAM QUINN
Credential	:	PH.D
Telephone Number	:	706-369-9707

Provider Enumeration Date	:	02/27/2014
Last Update Date	:	02/27/2014

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