MEDICARE: A CHANGE COUNSELING CENTER 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	101Y00000X	Counselor	CP00000521	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1328	OTHER	WA	PREMERA BLUE CROSS ID

General Provider Information

NPI Number	:	1457458721
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A CHANGE COUNSELING CENTER INC.

Provider Business Mailing Address
First Line	:	4002 S M ST STE C
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98418-3800
Country	:	US
Telephone Number	:	253-473-1844
Fax Number	:	253-473-1839

Provider Business Practice Location Address
First Line	:	4002 S M ST STE C
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98418-3800
Country	:	US
Telephone Number	:	253-473-1844
Fax Number	:	253-473-1839

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. MELINDA J BROUSSARD
Credential	:
Telephone Number	:	253-473-1844

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	08/22/2020

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