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General NPI Number Information
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NPI Number | 1780009852
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Entity Type | Organization
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Legal Business Name | WAVES OF CHANGE COUNSELING SERVICES, LLC
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Dates
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Enumeration Date | 02/26/2014
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Last Update Date | 02/26/2014
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Provider Practice Location Address
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Address Line | 20730 HOLYOKE AVE SUITE 137
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City | LAKEVILLE
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State | MN
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Zip | 55044-9826
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Country | US
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Telephone | 612-567-0278
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 366
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City | LAKEVILLE
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State | MN
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Zip | 55044-0366
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Country | US
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Telephone | 612-567-0278
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Fax |
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Authorized Official
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Title or Position | LICENSED PROFESSIONAL COUNSELOR
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Name | BRYN TAYLOR
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Credential | LPC
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Telephone | 612-567-0278
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 01373
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License Number State | MN
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