=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740673698
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROGRESSIVE REFLECTION FOR CHANGE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2015
-----------------------------------------------------
Last Update Date | 11/11/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 157 S KALAMAZOO MALL SUITE 110
-----------------------------------------------------
City | KALAMAZOO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49007-4877
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-350-5661
-----------------------------------------------------
Fax | 269-350-5501
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 151 S ROSE ST SUITE 617
-----------------------------------------------------
City | KALAMAZOO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49007-4792
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-350-5661
-----------------------------------------------------
Fax | 269-350-5501
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. KATHLEEN RENE' WADE-JONES
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 269-350-5661
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 6801087438
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------