Healthcare Provider Details

I. General information

NPI: 1114356649
Provider Name (Legal Business Name): CHANGING COURSE COUNSELING, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2013
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3071 COMMERCE DR STE B
FORT GRATIOT MI
48059-3869
US

IV. Provider business mailing address

4131 FAIRWAY DR
FORT GRATIOT MI
48059-3905
US

V. Phone/Fax

Practice location:
  • Phone: 810-357-9318
  • Fax: 810-479-9684
Mailing address:
  • Phone: 810-357-9318
  • Fax: 810-479-9684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: KELLE S WOOD
Title or Position: LMSW/OWNER
Credential: LMSW
Phone: 810-357-9318