Provider Demographics
NPI:1649459132
Name:CENTER FOR CHANGE & GROWTH PLC
Entity type:Organization
Organization Name:CENTER FOR CHANGE & GROWTH PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:269-657-5800
Mailing Address - Street 1:816 E MICHIGAN AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079
Mailing Address - Country:US
Mailing Address - Phone:269-657-5800
Mailing Address - Fax:269-657-8939
Practice Address - Street 1:816 E MICHIGAN AVE STE 101
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-1462
Practice Address - Country:US
Practice Address - Phone:269-657-5800
Practice Address - Fax:269-657-8939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION98950Medicare UPIN