MEDICARE: WAVES OF CHANGE COALITION 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

General Provider Information

NPI Number	:	1508605940
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAVES OF CHANGE COALITION LLC

Provider Business Mailing Address
First Line	:	529 HYDE PARK RD
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23503-5513
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2380 LIBERTY WAY
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456-3466
Country	:	US
Telephone Number	:	757-773-2102
Fax Number	:

Authorized Official
Title or Position	:	OWNER/MANAGER
Name	:	CARLAN JONES
Credential	:	LCSW
Telephone Number	:	757-773-2102

Provider Enumeration Date	:	05/24/2024
Last Update Date	:	05/24/2024

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Directions to “WAVES OF CHANGE COALITION LLC ” Practice Location

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