Healthcare Provider Details

I. General information

NPI: 1124697727
Provider Name (Legal Business Name): IMPACTFUL CHANGES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2021
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2235 W SARATOGA ST
BALTIMORE MD
21223-1509
US

IV. Provider business mailing address

2235 W SARATOGA ST
BALTIMORE MD
21223-1509
US

V. Phone/Fax

Practice location:
  • Phone: 443-473-3416
  • Fax:
Mailing address:
  • Phone: 443-473-3416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: ARIKA DAVENPORT
Title or Position: CEO
Credential:
Phone: 443-473-3416