Healthcare Provider Details

I. General information

NPI: 1275338857
Provider Name (Legal Business Name): LIFE CHANGE THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2025
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 W GRAND RIVER AVE STE A
OKEMOS MI
48864-1604
US

IV. Provider business mailing address

PO BOX 143
CALUMET MI
49913-0143
US

V. Phone/Fax

Practice location:
  • Phone: 906-319-8725
  • Fax:
Mailing address:
  • Phone: 906-319-8725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: BRIGID EILLEEN HAVENS
Title or Position: OWNER
Credential: LPC
Phone: 906-319-8725