MEDICARE: OPEN DOOR CENTER FOR CHANGE 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1215068069
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPEN DOOR CENTER FOR CHANGE LLC

Provider Business Mailing Address
First Line	:	6502 GRAND TETON PLZ STE 102
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53719-1047
Country	:	US
Telephone Number	:	608-827-7220
Fax Number	:	608-827-7223

Provider Business Practice Location Address
First Line	:	6502 GRAND TETON PLZ STE 102
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53719-1047
Country	:	US
Telephone Number	:	608-827-7220
Fax Number	:	608-827-7223

Authorized Official
Title or Position	:	CO-OWNER
Name	:	MS. AMY J MOSHER-GARVEY
Credential	:	LCSW, CSAC
Telephone Number	:	608-827-7220

Provider Enumeration Date	:	03/07/2007
Last Update Date	:	03/07/2024

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Directions to “OPEN DOOR CENTER FOR CHANGE LLC ” Practice Location

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