Healthcare Provider Details

I. General information

NPI: 1952097701
Provider Name (Legal Business Name): HOLISTIC CHANGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2023
Last Update Date: 05/05/2023
Certification Date: 05/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 W COLD SPRING LN
BALTIMORE MD
21215-6702
US

IV. Provider business mailing address

11 GWYNNS MILL CT STE K
OWINGS MILLS MD
21117-3500
US

V. Phone/Fax

Practice location:
  • Phone: 800-395-9636
  • Fax:
Mailing address:
  • Phone: 443-468-6169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. JAMES BERNARD SCOTT III
Title or Position: OWNER
Credential:
Phone: 443-468-6169