Provider Demographics
NPI:1043657075
Name:AVENUES OF CHANGE
Entity Type:Organization
Organization Name:AVENUES OF CHANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LPC
Authorized Official - Prefix:
Authorized Official - First Name:MARYANN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMOLKO-SELF
Authorized Official - Suffix:
Authorized Official - Credentials:7707134574
Authorized Official - Phone:770-713-4574
Mailing Address - Street 1:132 GALLERY COURT
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101
Mailing Address - Country:US
Mailing Address - Phone:770-713-4574
Mailing Address - Fax:
Practice Address - Street 1:1568 CLOVERDALE DR SE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-7406
Practice Address - Country:US
Practice Address - Phone:770-713-4574
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-31
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004657101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty