Healthcare Provider Details

I. General information

NPI: 1407035918
Provider Name (Legal Business Name): CHANGE LANES YOUTH SUPPORT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2007
Last Update Date: 12/31/2021
Certification Date: 12/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45118 13TH ST W
LANCASTER CA
93534-2156
US

IV. Provider business mailing address

45118 13TH STREET WEST UNIT 1D
LANCASTER CA
93534-2156
US

V. Phone/Fax

Practice location:
  • Phone: 661-948-5555
  • Fax: 661-878-9130
Mailing address:
  • Phone: 661-948-2555
  • Fax: 661-878-9130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number10007140
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number10023326
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number10007140
License Number StateCA

VIII. Authorized Official

Name: MRS. CYNTHIA D. HUNTER-SPEARS
Title or Position: EXECUTIVE DIRECTOR
Credential: MA, CATC
Phone: 661-948-2555