MEDICARE: CHANGES PREMIER HEALTH , 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	261QM0850X	Adult Mental Health Clinic/Center
2	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1174089569
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHANGES PREMIER HEALTH , LLC

Provider Business Mailing Address
First Line	:	1820 N LAKE FOREST DR STE 100
Second Line	:
City	:	MCKINNEY
State	:	TX
Zip	:	75071-7653
Country	:	US
Telephone Number	:	469-634-1270
Fax Number	:	469-634-1271

Provider Business Practice Location Address
First Line	:	1820 N LAKE FOREST DR STE 100
Second Line	:
City	:	MCKINNEY
State	:	TX
Zip	:	75071-7653
Country	:	US
Telephone Number	:	469-634-1270
Fax Number	:	469-634-1271

Authorized Official
Title or Position	:	MARKET CEO
Name	:	SAMANTHA CASTLE
Credential	:
Telephone Number	:	972-428-0527

Provider Enumeration Date	:	02/11/2019
Last Update Date	:	02/11/2019

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