1912354184 NPI number — CHANGING LIVES AT HOME MENTAL HEALTH CORPORATION

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 1912354184 NPI number — CHANGING LIVES AT HOME MENTAL HEALTH CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHANGING LIVES AT HOME MENTAL HEALTH CORPORATION
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:
1912354184
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
05/22/2023
NPI Reactivation Date:
07/10/2023

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
202 GLENN ELLEN CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PIKESVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21208-1028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-463-9523
Provider Business Mailing Address Fax Number:
410-510-1982

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4805 GARRISON BLVD
Provider Second Line Business Practice Location Address:
1ST FLOOR AND SUITE 200
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21215-5695
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-465-9523
Provider Business Practice Location Address Fax Number:
410-510-1982
Provider Enumeration Date:
05/18/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BRYANT-BASS
Authorized Official First Name:
LATRILL
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO/DIRCTOR
Authorized Official Telephone Number:
443-463-9523

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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