MEDICARE: COUNSELING CENTER FOR DISCOVERY & 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	101YA0400X	Addiction (Substance Use Disorder) Counselor	1114	CT
2	101YP2500X	Professional Counselor	2519	CT

General Provider Information

NPI Number	:	1548654254
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNSELING CENTER FOR DISCOVERY & CHANGE LLC

Provider Business Mailing Address
First Line	:	12 CUSTER ST
Second Line	:
City	:	STAMFORD
State	:	CT
Zip	:	06902-3128
Country	:	US
Telephone Number	:	203-249-5334
Fax Number	:

Provider Business Practice Location Address
First Line	:	12 CUSTER ST
Second Line	:
City	:	STAMFORD
State	:	CT
Zip	:	06902-3128
Country	:	US
Telephone Number	:	203-249-5334
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ROODY JOSEPH
Credential	:	LPC
Telephone Number	:	203-249-5334

Provider Enumeration Date	:	03/20/2015
Last Update Date	:	03/20/2015

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