MEDICARE: SEED OF CHANGE COUNSELING AND NEUROTHERAPY, PLLC

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	101YP2500X	Professional Counselor	LPC.0012243	CO

General Provider Information

NPI Number	:	1437666096
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEED OF CHANGE COUNSELING AND NEUROTHERAPY, PLLC

Provider Business Mailing Address
First Line	:	2906 BEACON ST STE B
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80907-6193
Country	:	US
Telephone Number	:	719-629-8574
Fax Number	:	719-213-2839

Provider Business Practice Location Address
First Line	:	2906 BEACON ST STE B
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80907-6193
Country	:	US
Telephone Number	:	719-629-8574
Fax Number	:	719-213-2839

Authorized Official
Title or Position	:	OWNER/THERAPIST
Name	:	DR. AMY LONG
Credential	:	PSY.D, LPC
Telephone Number	:	719-629-8574

Provider Enumeration Date	:	01/04/2018
Last Update Date	:	01/04/2018

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