=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164925905
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POSITIVE CHANGE COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2018
-----------------------------------------------------
Last Update Date | 03/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 88 PARK ST
-----------------------------------------------------
City | MONTCLAIR
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07042-5915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 862-216-0254
-----------------------------------------------------
Fax | 973-233-4473
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 88 PARK ST
-----------------------------------------------------
City | MONTCLAIR
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07042-5915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 862-216-0254
-----------------------------------------------------
Fax | 973-233-4473
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. JEFFREY HUGUES
-----------------------------------------------------
Credential | MSW LCSW
-----------------------------------------------------
Telephone | 862-216-0254
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 44SC05389000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------