MEDICARE: CHANGING MINDS MENTAL HEALTH SERVICES LLC

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	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1144788951
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHANGING MINDS MENTAL HEALTH SERVICES LLC

Provider Business Mailing Address
First Line	:	1482 MUNSON ST
Second Line	:
City	:	BURTON
State	:	MI
Zip	:	48509-1836
Country	:	US
Telephone Number	:	810-610-9164
Fax Number	:	810-746-5050

Provider Business Practice Location Address
First Line	:	12750 S SAGINAW ST STE 203
Second Line	:
City	:	GRAND BLANC
State	:	MI
Zip	:	48439-1841
Country	:	US
Telephone Number	:	810-610-9164
Fax Number	:	810-746-5050

Authorized Official
Title or Position	:	LICENSED PROFESSIONAL COUNSELOR/OWN
Name	:	PAMALA KAY DAVIS
Credential	:	MA LPC
Telephone Number	:	810-610-9164

Provider Enumeration Date	:	03/11/2019
Last Update Date	:	03/11/2019

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