MEDICARE: LIFE CHANGES COUNSELING 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	1041C0700X	Clinical Social Worker	CSW003482	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1073577557	OTHER	GA	NPI UNDER SSN

General Provider Information

NPI Number	:	1275664831
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE CHANGES COUNSELING LLC

Provider Business Mailing Address
First Line	:	105 WELLINGTON DR
Second Line	:
City	:	PERRY
State	:	GA
Zip	:	31069-9713
Country	:	US
Telephone Number	:	478-397-6209
Fax Number	:	478-922-1778

Provider Business Practice Location Address
First Line	:	121 CARL VINSON PKWY
Second Line	:	PSYCHOLOGICAL OFFICES
City	:	WARNER ROBINS
State	:	GA
Zip	:	31088-5817
Country	:	US
Telephone Number	:	478-922-2365
Fax Number	:	478-922-1778

Authorized Official
Title or Position	:	LCSW
Name	:	MS. SUSAN DAVIS FEEHAN
Credential	:	LCSW
Telephone Number	:	478-397-6209

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	08/22/2020

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