MEDICARE: GAME CHANGER PEDIATRIC THERAPY SERVICES 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	225XP0200X	Pediatric Occupational Therapist	5201009073	MI

General Provider Information

NPI Number	:	1437506383
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GAME CHANGER PEDIATRIC THERAPY SERVICES LLC

Provider Business Mailing Address
First Line	:	PO BOX 3272
Second Line	:
City	:	SAGINAW
State	:	MI
Zip	:	48605-3272
Country	:	US
Telephone Number	:	989-797-1400
Fax Number	:	989-797-4077

Provider Business Practice Location Address
First Line	:	3727 WILDER RD STE A&B
Second Line	:
City	:	BAY CITY
State	:	MI
Zip	:	48706-2367
Country	:	US
Telephone Number	:	989-980-9747
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SCOTT STASZAK
Credential	:
Telephone Number	:	989-860-0846

Provider Enumeration Date	:	05/20/2016
Last Update Date	:	01/12/2022

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