Provider Demographics
NPI: | 1033633300 |
---|---|
Name: | CHANGE YOUR DESTINY COUNSELING LLC |
Entity Type: | Organization |
Organization Name: | CHANGE YOUR DESTINY COUNSELING LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | LPC |
Authorized Official - Prefix: | |
Authorized Official - First Name: | MARLINA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | BROWN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 313-544-0199 |
Mailing Address - Street 1: | 8913 GABRIEL ST |
Mailing Address - Street 2: | |
Mailing Address - City: | ROMULUS |
Mailing Address - State: | MI |
Mailing Address - Zip Code: | 48174-4133 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 2000 TOWN CTR STE 1900 |
Practice Address - Street 2: | |
Practice Address - City: | SOUTHFIELD |
Practice Address - State: | MI |
Practice Address - Zip Code: | 48075-1152 |
Practice Address - Country: | US |
Practice Address - Phone: | 248-733-5142 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2017-07-28 |
Last Update Date: | 2017-07-28 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MI | 6401012941 | 101YP2500X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | Group - Multi-Specialty |