Healthcare Provider Details

I. General information

NPI: 1144162835
Provider Name (Legal Business Name): CHANGING LIVES WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2026
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 KENMOOR AVE SE # 150434
GRAND RAPIDS MI
49546-2395
US

IV. Provider business mailing address

625 KENMOOR AVE SE # 150434
GRAND RAPIDS MI
49546-2395
US

V. Phone/Fax

Practice location:
  • Phone: 248-413-5013
  • Fax:
Mailing address:
  • Phone: 248-413-5013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BRIAN MANGENJE
Title or Position: OWNER / NP / PROVIDER
Credential: FNP-BC, PMHNP-BC/C
Phone: 248-413-5013