Healthcare Provider Details

I. General information

NPI: 1588575245
Provider Name (Legal Business Name): NOURISHING CHANGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1476 KENWOOD DR STE 102
MENASHA WI
54952-1134
US

IV. Provider business mailing address

1476 KENWOOD DR STE 102
MENASHA WI
54952-1134
US

V. Phone/Fax

Practice location:
  • Phone: 920-939-8868
  • Fax: 920-939-7042
Mailing address:
  • Phone: 920-939-8868
  • Fax: 920-939-7042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: AMY MEGAN TAAKE
Title or Position: OWNER/ THERAPIST
Credential: LPC, SAC
Phone: 920-939-8868