Healthcare Provider Details

I. General information

NPI: 1528707643
Provider Name (Legal Business Name): CHANGING LANES INTERVENTION HUMAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2022
Last Update Date: 04/12/2024
Certification Date: 04/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 LANIER AVE W STE 608
FAYETTEVILLE GA
30214-7644
US

IV. Provider business mailing address

500 LANIER AVE W STE 608
FAYETTEVILLE GA
30214-7644
US

V. Phone/Fax

Practice location:
  • Phone: 770-580-4116
  • Fax: 888-522-1055
Mailing address:
  • Phone: 770-256-3977
  • Fax: 888-522-1055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY MARTIN
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: LPC,LBA,BCBA,CRPS
Phone: 770-580-4116