Provider Demographics
NPI:1669918231
Name:FOSTERING CHANGE COUNSELING SERVICES LLC
Entity type:Organization
Organization Name:FOSTERING CHANGE COUNSELING SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:JUSTAVIS
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-447-9722
Mailing Address - Street 1:3031 BROCKHAM CT
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-0629
Mailing Address - Country:US
Mailing Address - Phone:706-945-9731
Mailing Address - Fax:
Practice Address - Street 1:2826 HILLCREEK DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-5628
Practice Address - Country:US
Practice Address - Phone:706-447-9722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-06
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1518339878Medicare PIN