Provider Demographics
NPI:1326707399
Name:PROMINENT LIFE CHANGES THERAPY GROUP. P.C.
Entity Type:Organization
Organization Name:PROMINENT LIFE CHANGES THERAPY GROUP. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:VAUGHTER
Authorized Official - Suffix:
Authorized Official - Credentials:LLMSW
Authorized Official - Phone:586-942-1430
Mailing Address - Street 1:PO BOX 1434
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099
Mailing Address - Country:US
Mailing Address - Phone:586-942-1430
Mailing Address - Fax:
Practice Address - Street 1:2844 LIVERNOIS ROAD
Practice Address - Street 2:UNIT 1434
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48099
Practice Address - Country:US
Practice Address - Phone:586-942-1430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-16
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1417419318Medicaid