MEDICARE: FOSTERING CHANGE COUNSELING SERVICES 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	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1669918231
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOSTERING CHANGE COUNSELING SERVICES LLC

Provider Business Mailing Address
First Line	:	3031 BROCKHAM CT
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30909-0629
Country	:	US
Telephone Number	:	706-945-9731
Fax Number	:

Provider Business Practice Location Address
First Line	:	2826 HILLCREEK DR
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30909-5628
Country	:	US
Telephone Number	:	706-447-9722
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	CARLOS JUSTAVIS FOSTER
Credential	:
Telephone Number	:	706-447-9722

Provider Enumeration Date	:	01/06/2017
Last Update Date	:	01/18/2024

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