Basic Information
| Provider Information | |||||||||
| NPI: | 1275664831 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIFE CHANGES COUNSELING LLC | ||||||||
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| OtherOrganizationName: | SUSAN FEEHAN, LCSW | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 WELLINGTON DR | ||||||||
| Address2: | |||||||||
| City: | PERRY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310699713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4783976209 | ||||||||
| FaxNumber: | 4789221778 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 CARL VINSON PKWY | ||||||||
| Address2: | PSYCHOLOGICAL OFFICES | ||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310885817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789222365 | ||||||||
| FaxNumber: | 4789221778 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | FEEHAN | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | DAVIS | ||||||||
| AuthorizedOfficialTitleorPosition: | LCSW | ||||||||
| AuthorizedOfficialTelephone: | 4783976209 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | CSW003482 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1073577557 | 01 | GA | NPI UNDER SSN | OTHER |