MEDICARE: UPWARD CHANGE HEALTH SERVICE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	253Z00000X	In Home Supportive Care Agency	P007600	NC

General Provider Information

NPI Number	:	1659782332
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UPWARD CHANGE HEALTH SERVICE

Provider Business Mailing Address
First Line	:	807 E MAIN ST
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27701-4074
Country	:	US
Telephone Number	:	919-682-5300
Fax Number	:

Provider Business Practice Location Address
First Line	:	807 E MAIN ST
Second Line	:	APT 2931
City	:	DURHAM
State	:	NC
Zip	:	27701-4074
Country	:	US
Telephone Number	:	919-682-5300
Fax Number	:

Authorized Official
Title or Position	:	TEAM LEAD, CLINICAL THERAPIST
Name	:	MRS. LATASHA MACHELLE-KELLY SMITH
Credential	:	LCSW-A
Telephone Number	:	910-778-3049

Provider Enumeration Date	:	05/15/2014
Last Update Date	:	05/15/2014

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