MEDICARE: WAVES OF CHANGE, 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	101YM0800X	Mental Health Counselor	4680	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4680	OTHER	NC	LICENCED PROFESSIONAL COUNSELOR

General Provider Information

NPI Number	:	1932360724
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAVES OF CHANGE, PLLC

Provider Business Mailing Address
First Line	:	104 MARY LN
Second Line	:
City	:	NEWPORT
State	:	NC
Zip	:	28570-9416
Country	:	US
Telephone Number	:	252-241-6156
Fax Number	:

Provider Business Practice Location Address
First Line	:	215 N 35TH ST
Second Line	:	SUITE 5
City	:	MOREHEAD CITY
State	:	NC
Zip	:	28557-3185
Country	:	US
Telephone Number	:	252-725-0797
Fax Number	:

Authorized Official
Title or Position	:	MANAGER/OWNER/COUNSELOR
Name	:	MS. JEANNIE ELIZABETH ADAIR
Credential	:	LPC
Telephone Number	:	252-725-0797

Provider Enumeration Date	:	06/24/2008
Last Update Date	:	06/07/2009

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Directions to “WAVES OF CHANGE, PLLC ” Practice Location

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