MEDICARE: COBIELLA CENTER FOR CHANGE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	650238748	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1568551828	OTHER	FL	IND. NPI #
2	1285723668	OTHER	FL	IND. NPI #

General Provider Information

NPI Number	:	1013199082
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COBIELLA CENTER FOR CHANGE, INC.

Provider Business Mailing Address
First Line	:	953 NE JENSEN BEACH BLVD
Second Line	:
City	:	JENSEN BEACH
State	:	FL
Zip	:	34957-4705
Country	:	US
Telephone Number	:	772-225-1224
Fax Number	:

Provider Business Practice Location Address
First Line	:	953 NE JENSEN BEACH BLVD
Second Line	:
City	:	JENSEN BEACH
State	:	FL
Zip	:	34957-4705
Country	:	US
Telephone Number	:	772-225-1224
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. DEBBIE MULACH
Credential	:
Telephone Number	:	772-225-1224

Provider Enumeration Date	:	12/03/2007
Last Update Date	:	01/05/2011

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