=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619256799
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERSONAL CHOICE PLANNED CHANGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2011
-----------------------------------------------------
Last Update Date | 11/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4432 KNIGHTSBRIDGE LN
-----------------------------------------------------
City | WEST BLOOMFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48323-1627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-363-1976
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4432 KNIGHTSBRIDGE LN
-----------------------------------------------------
City | WEST BLOOMFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48323-1627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-363-1976
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/DIRECTOR
-----------------------------------------------------
Name | ROSLYN JO CARTER
-----------------------------------------------------
Credential | MA, LPC
-----------------------------------------------------
Telephone | 313-363-1976
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 6401004803
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------