1265713705 NPI number — CHANGING CYCLES, LLC

Table of content: SARA ALISHA POUND BCBA (NPI 1134583214)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265713705 NPI number — CHANGING CYCLES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHANGING CYCLES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265713705
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3475 LEONARDTOWN RD
Provider Second Line Business Mailing Address:
SUITE 206
Provider Business Mailing Address City Name:
WALDORF
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20601-3678
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-357-6605
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14460 OLD MILL RD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
UPPER MARLBORO
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20772-3092
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-357-6605
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/29/2011

Additional Information

Authorized Official

Authorized Official Last Name:
THOMAS-KELLY
Authorized Official First Name:
KEYONA
Authorized Official Middle Name:
SHANTRICE
Authorized Official Title or Position:
VICE-PRESIDENT AND COO
Authorized Official Telephone Number:
301-357-6605

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  PRC13986 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: LC2555 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 440314200 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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