MEDICARE: AGENCY OF CHANGE

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	SW8327	FL

General Provider Information

NPI Number	:	1407153885
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AGENCY OF CHANGE

Provider Business Mailing Address
First Line	:	900 NE 18TH AVE
Second Line	:	1207
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-3063
Country	:	US
Telephone Number	:	954-524-6861
Fax Number	:

Provider Business Practice Location Address
First Line	:	900 NE 18TH AVE
Second Line	:	1207
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-3063
Country	:	US
Telephone Number	:	954-524-6861
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. MELANIE DONOHUE
Credential	:	LCSW
Telephone Number	:	954-465-5142

Provider Enumeration Date	:	02/20/2011
Last Update Date	:	02/20/2011

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Directions to “AGENCY OF CHANGE ” Practice Location

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