Healthcare Provider Details

I. General information

NPI: 1649459132
Provider Name (Legal Business Name): CENTER FOR CHANGE & GROWTH PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2007
Last Update Date: 11/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 E MICHIGAN AVE STE 101
PAW PAW MI
49079-1462
US

IV. Provider business mailing address

816 E MICHIGAN AVE STE 101
PAW PAW MI
49079
US

V. Phone/Fax

Practice location:
  • Phone: 269-657-5800
  • Fax: 269-657-8939
Mailing address:
  • Phone: 269-657-5800
  • Fax: 269-657-8939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SUSAN MARIE CARTER
Title or Position: CLINICAL DIRECTOR OWNER
Credential: PHD
Phone: 269-657-5800