=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457458721
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A CHANGE COUNSELING CENTER INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4002 S M ST STE C
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98418-3800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-473-1844
-----------------------------------------------------
Fax | 253-473-1839
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4002 S M ST STE C
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98418-3800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-473-1844
-----------------------------------------------------
Fax | 253-473-1839
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. MELINDA J BROUSSARD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 253-473-1844
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | CP00000521
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------