Healthcare Provider Details

I. General information

NPI: 1649458126
Provider Name (Legal Business Name): CHANGING SEASONS COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 02/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2012 10TH ST
MENOMINEE MI
49858-2194
US

IV. Provider business mailing address

2012 10TH ST
MENOMINEE MI
49858-2194
US

V. Phone/Fax

Practice location:
  • Phone: 906-863-5646
  • Fax: 906-863-1078
Mailing address:
  • Phone: 906-863-5646
  • Fax: 906-863-1078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL JAY GIBSON
Title or Position: OWNER/THERAPIST
Credential: ED.D
Phone: 906-863-5646