=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942803945
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHOOSE YOUR CHANGE COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2020
-----------------------------------------------------
Last Update Date | 06/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 S AUBURN RD
-----------------------------------------------------
City | AUBURN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48611-9366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-545-1358
-----------------------------------------------------
Fax | 989-393-2012
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3333 PARKWAY DR
-----------------------------------------------------
City | BAY CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48706-6201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-274-8891
-----------------------------------------------------
Fax | 989-393-2012
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROFESSIONAL COUNSELOR
-----------------------------------------------------
Name | AMY FOLSOM
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 989-545-1358
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------