1093458051 NPI number — CULTIVATING CHANGE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093458051 NPI number — CULTIVATING CHANGE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CULTIVATING CHANGE
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:
6
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:
1093458051
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/28/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2512 N. CHARLES STREET
Provider Second Line Business Mailing Address:
1ST FLOOR/B
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21218-4645
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-493-3372
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2512 N. CHARLES STREET
Provider Second Line Business Practice Location Address:
1ST FLOOR/B
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21218-4645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-493-3372
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/18/2022

Additional Information

Authorized Official

Authorized Official Last Name:
WALKER
Authorized Official First Name:
DELORA
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
410-493-3372

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1558019489 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com