MEDICARE: INTENTIONAL CHANGE THERAPY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101YM0800X	Mental Health Counselor
2	104100000X	Social Worker
3	106H00000X	Marriage & Family Therapist
4	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1801631239
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTENTIONAL CHANGE THERAPY, LLC

Provider Business Mailing Address
First Line	:	P.O. BOX 603249
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44103-0249
Country	:	US
Telephone Number	:	412-657-5513
Fax Number	:

Provider Business Practice Location Address
First Line	:	2233 E. 81ST ST.
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44103-5003
Country	:	US
Telephone Number	:	412-657-5513
Fax Number	:

Authorized Official
Title or Position	:	MENTAL HEALTH THERAPIST
Name	:	LATANYA PERDUE
Credential	:	LISW
Telephone Number	:	412-657-5513

Provider Enumeration Date	:	06/27/2024
Last Update Date	:	06/27/2024

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Directions to “INTENTIONAL CHANGE THERAPY, LLC ” Practice Location

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