MEDICARE: CHANGING COURSE COUNSELING, PLC

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	261QM0850X	Adult Mental Health Clinic/Center
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1114356649
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHANGING COURSE COUNSELING, PLC

Provider Business Mailing Address
First Line	:	4131 FAIRWAY DR
Second Line	:
City	:	FORT GRATIOT
State	:	MI
Zip	:	48059-3905
Country	:	US
Telephone Number	:	810-357-9318
Fax Number	:	810-479-9684

Provider Business Practice Location Address
First Line	:	3071 COMMERCE DR STE B
Second Line	:
City	:	FORT GRATIOT
State	:	MI
Zip	:	48059-3869
Country	:	US
Telephone Number	:	810-357-9318
Fax Number	:	810-479-9684

Authorized Official
Title or Position	:	LMSW/OWNER
Name	:	KELLE S WOOD
Credential	:	LMSW
Telephone Number	:	810-357-9318

Provider Enumeration Date	:	11/05/2013
Last Update Date	:	08/07/2024

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