MEDICARE: LIFE CHANGE THERAPY LLC

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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1275338857
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE CHANGE THERAPY LLC

Provider Business Mailing Address
First Line	:	2222 W GRAND RIVER AVE STE A
Second Line	:
City	:	OKEMOS
State	:	MI
Zip	:	48864-1604
Country	:	US
Telephone Number	:	906-319-8725
Fax Number	:

Provider Business Practice Location Address
First Line	:	4612 PLAINFIELD AVE NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-1229
Country	:	US
Telephone Number	:	906-319-8725
Fax Number	:

Authorized Official
Title or Position	:	COUNSELOR
Name	:	BRIGID HAVENS
Credential	:	LPC
Telephone Number	:	906-319-8725

Provider Enumeration Date	:	02/17/2025
Last Update Date	:	06/02/2026

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Directions to “LIFE CHANGE THERAPY LLC ” Practice Location

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