MEDICARE: CHANGING HABITS

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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center	07570128	KS

General Provider Information

NPI Number	:	1871833285
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHANGING HABITS

Provider Business Mailing Address
First Line	:	1115 S GLENDALE ST STE 204
Second Line	:	PARKLANE SHOPPING CENTER LOWER LEVEL
City	:	WICHITA
State	:	KS
Zip	:	67218-3232
Country	:	US
Telephone Number	:	316-409-5242
Fax Number	:	316-719-2440

Provider Business Practice Location Address
First Line	:	1115 S GLENDALE ST STE 204
Second Line	:	PARKLANE SHOPPING CENTER LOWER LEVEL
City	:	WICHITA
State	:	KS
Zip	:	67218-3232
Country	:	US
Telephone Number	:	316-409-5242
Fax Number	:	316-719-2440

Authorized Official
Title or Position	:	OWNER
Name	:	MR. DAVID BRIAN SIMMONS
Credential	:	LAC
Telephone Number	:	316-409-5242

Provider Enumeration Date	:	02/21/2013
Last Update Date	:	12/22/2015

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Directions to “CHANGING HABITS ” Practice Location

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