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General NPI Number Information
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NPI Number | 1740957133
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Entity Type | Organization
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Legal Business Name | SPACE FOR CHANGE THERAPEUTIC SERVICES, LLC
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Dates
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Enumeration Date | 08/24/2021
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Last Update Date | 08/24/2021
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Provider Practice Location Address
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Address Line | 1352 BALDWIN ST
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City | JENISON
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State | MI
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Zip | 49428-8937
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Country | US
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Telephone | 616-322-3803
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Fax |
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Provider Business Mailing Address
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Address Line | 1352 BALDWIN ST
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City | JENISON
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State | MI
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Zip | 49428-8937
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Country | US
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Telephone | 616-322-3803
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Fax |
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Authorized Official
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Title or Position | LEAD THERAPIST
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Name | TASHUNA HUNT
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Credential | LMSW
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Telephone | 616-322-3803
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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