MEDICARE: AGEWELL FAMILY COUNSELING, 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	1041C0700X	Clinical Social Worker	6801089424	MI

General Provider Information

NPI Number	:	1699170266
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AGEWELL FAMILY COUNSELING, LLC

Provider Business Mailing Address
First Line	:	167 OLD PERCH RD
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48309-2135
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	167 OLD PERCH RD
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48309-2135
Country	:	US
Telephone Number	:	810-874-0857
Fax Number	:

Authorized Official
Title or Position	:	FOUNDING MEMBER
Name	:	YULIYA GAYDAYENKO
Credential	:	LMSW
Telephone Number	:	810-874-0857

Provider Enumeration Date	:	10/24/2014
Last Update Date	:	12/26/2014

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