MEDICARE: CHANGE AGENTS, INC.

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	CSW004040	GA

General Provider Information

NPI Number	:	1356596027
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHANGE AGENTS, INC.

Provider Business Mailing Address
First Line	:	3599 CREEKWOOD LN SW
Second Line	:
City	:	SMYRNA
State	:	GA
Zip	:	30082-2901
Country	:	US
Telephone Number	:	404-447-2845
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 VILLAGE GREEN CIR SE
Second Line	:	SUITE 201
City	:	SMYRNA
State	:	GA
Zip	:	30080-3476
Country	:	US
Telephone Number	:	404-447-2845
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MRS. JOAN TOLBERT MERRIWEATHER
Credential	:	LCSW
Telephone Number	:	404-447-2845

Provider Enumeration Date	:	11/22/2008
Last Update Date	:	04/17/2009

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