Provider Demographics
NPI:1528689122
Name:ICHOOSE CHANGE, LLC
Entity type:Organization
Organization Name:ICHOOSE CHANGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSELYN
Authorized Official - Middle Name:L
Authorized Official - Last Name:BURNETT
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:321-339-7736
Mailing Address - Street 1:570 MALABAR RD SW APT 102
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-3312
Mailing Address - Country:US
Mailing Address - Phone:321-339-7736
Mailing Address - Fax:
Practice Address - Street 1:1600 MALABAR RD
Practice Address - Street 2:J-119
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-1408
Practice Address - Country:US
Practice Address - Phone:321-205-7790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-05
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty