MEDICARE: PATH TO CHANGE, 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	101YP2500X	Professional Counselor	007009	GA

General Provider Information

NPI Number	:	1467987883
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATH TO CHANGE, LLC

Provider Business Mailing Address
First Line	:	314 TRIBBLE GAP RD STE B
Second Line	:
City	:	CUMMING
State	:	GA
Zip	:	30040-2475
Country	:	US
Telephone Number	:	770-615-6115
Fax Number	:	678-403-0334

Provider Business Practice Location Address
First Line	:	314 TRIBBLE GAP RD STE B
Second Line	:
City	:	CUMMING
State	:	GA
Zip	:	30040-2475
Country	:	US
Telephone Number	:	770-615-6115
Fax Number	:	678-403-0334

Authorized Official
Title or Position	:	OWNER
Name	:	HEATHER COBB
Credential	:	MA LPC
Telephone Number	:	770-615-6115

Provider Enumeration Date	:	04/23/2017
Last Update Date	:	04/23/2017

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