MEDICARE: CHANGES

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	251S00000X	Community/Behavioral Health Agency		FL

General Provider Information

NPI Number	:	1790116093
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHANGES

Provider Business Mailing Address
First Line	:	1156 LAMPLIGHTER DR NW
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32907-7936
Country	:	US
Telephone Number	:	321-591-3248
Fax Number	:

Provider Business Practice Location Address
First Line	:	1156 LAMPLIGHTER DR NW
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32907-7936
Country	:	US
Telephone Number	:	321-591-3248
Fax Number	:

Authorized Official
Title or Position	:	CLINICIAN
Name	:	ROLLAND NICOLAS
Credential	:	MSW
Telephone Number	:	321-591-3248

Provider Enumeration Date	:	12/11/2013
Last Update Date	:	12/11/2013

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Directions to “CHANGES ” Practice Location

Language	Start Address	Practice Location

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