=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114630076
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVENUES FOR CHANGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2023
-----------------------------------------------------
Last Update Date | 04/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 809 S PATTON RD
-----------------------------------------------------
City | GREAT BEND
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67530-4620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-796-2206
-----------------------------------------------------
Fax | 866-288-1782
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1223
-----------------------------------------------------
City | GREAT BEND
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67530-1223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-796-2206
-----------------------------------------------------
Fax | 866-288-1782
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | KELLEY JOHNSON
-----------------------------------------------------
Credential | LCPC-S, LCAC
-----------------------------------------------------
Telephone | 620-796-2206
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------