Provider Demographics
NPI:1376765743
Name:CHOICES FOR CHANGE
Entity Type:Organization
Organization Name:CHOICES FOR CHANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:LEONORA
Authorized Official - Last Name:KOSS
Authorized Official - Suffix:
Authorized Official - Credentials:MASTERS PSYCHOLOGIST
Authorized Official - Phone:269-344-7997
Mailing Address - Street 1:6418 CYPRESS STREEET
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002
Mailing Address - Country:US
Mailing Address - Phone:269-327-3144
Mailing Address - Fax:
Practice Address - Street 1:218 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5131
Practice Address - Country:US
Practice Address - Phone:269-344-7997
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008528103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6301008528OtherLIMITED LICENSED PSYCHOLO