MEDICARE: TRANSFORMATIVE VISION PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	251S00000X	Community/Behavioral Health Agency
2	261QM0850X	Adult Mental Health Clinic/Center
3	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1952923039
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRANSFORMATIVE VISION PLLC

Provider Business Mailing Address
First Line	:	PO BOX 82406
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70884-2406
Country	:	US
Telephone Number	:	704-879-1179
Fax Number	:	704-490-4274

Provider Business Practice Location Address
First Line	:	227 W 4TH ST STE 321
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28202-1545
Country	:	US
Telephone Number	:	704-879-1179
Fax Number	:	704-490-4274

Authorized Official
Title or Position	:	CLINICIAL DIRECTOR
Name	:	JACQUELINE BUSH
Credential	:	LMFT, BC-TMH
Telephone Number	:	704-879-1179

Provider Enumeration Date	:	05/12/2020
Last Update Date	:	03/04/2026

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