MEDICARE: INITIATIVE FOR CHANGE & DEVELOPMENT COUNSELING SERVICES, 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	251S00000X	Community/Behavioral Health Agency	11387	TX

General Provider Information

NPI Number	:	1629473772
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INITIATIVE FOR CHANGE & DEVELOPMENT COUNSELING SERVICES, PLLC

Provider Business Mailing Address
First Line	:	1300 MCGOWEN ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77004-1141
Country	:	US
Telephone Number	:	713-714-8538
Fax Number	:	713-714-8841

Provider Business Practice Location Address
First Line	:	1300 MCGOWEN ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77004-1141
Country	:	US
Telephone Number	:	713-714-8538
Fax Number	:	713-714-8841

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. ALAN ROY BLACKSHEAR
Credential	:	LCDC, CART, COPSD
Telephone Number	:	713-714-8539

Provider Enumeration Date	:	10/31/2014
Last Update Date	:	10/31/2014

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