MEDICARE: THE CHANGE STUDIO

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	6401010358	MI

General Provider Information

NPI Number	:	1548625080
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE CHANGE STUDIO

Provider Business Mailing Address
First Line	:	959 LAKE DR SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49506-1447
Country	:	US
Telephone Number	:	616-259-5033
Fax Number	:	616-452-1024

Provider Business Practice Location Address
First Line	:	959 LAKE DR SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49506-1447
Country	:	US
Telephone Number	:	616-259-5033
Fax Number	:	616-452-1024

Authorized Official
Title or Position	:	OWNER/THERAPIST
Name	:	MS. DANA PATRICIA PRICE
Credential	:	MA, LPC
Telephone Number	:	616-259-5033

Provider Enumeration Date	:	12/29/2015
Last Update Date	:	12/29/2015

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Directions to “THE CHANGE STUDIO ” Practice Location

Language	Start Address	Practice Location

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