=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134779424
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTER FOR POSITIVE CHANGE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2019
-----------------------------------------------------
Last Update Date | 09/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11207 SERENBE LANE
-----------------------------------------------------
City | HILLS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-420-4325
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11207 SERENBE LANE
-----------------------------------------------------
City | HILLS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-420-4325
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PROFESSIONAL COUNSELOR
-----------------------------------------------------
Name | KATHLEEN ANN RASMUSSEN
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 920-420-4325
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------