=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134544117
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILIES 4 CHANGE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2014
-----------------------------------------------------
Last Update Date | 02/27/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1551 JENNINGS MILL RD SUITE 3100B
-----------------------------------------------------
City | BOGART
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30622-2544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-369-9707
-----------------------------------------------------
Fax | 706-369-9708
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1551 JENNINGS MILL RD SUITE 3100B
-----------------------------------------------------
City | BOGART
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30622-2544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-369-9707
-----------------------------------------------------
Fax | 706-369-9708
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | DR. WILLIAM QUINN
-----------------------------------------------------
Credential | PH.D
-----------------------------------------------------
Telephone | 706-369-9707
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 000480
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------