Provider Demographics
NPI:1053983536
Name:KWESELE, CHANGE
Entity type:Individual
Prefix:
First Name:CHANGE
Middle Name:
Last Name:KWESELE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHANGE
Other - Middle Name:
Other - Last Name:KWESELE MALAMA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:411 W LAKE LANSING RD STE C120
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-8483
Mailing Address - Country:US
Mailing Address - Phone:517-215-5217
Mailing Address - Fax:
Practice Address - Street 1:411 W LAKE LANSING RD STE C120
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-8483
Practice Address - Country:US
Practice Address - Phone:517-215-5217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011062131041C0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical