Healthcare Provider Details

I. General information

NPI: 1720641509
Provider Name (Legal Business Name): PROCESS OF CHANGES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2019
Last Update Date: 05/06/2020
Certification Date: 05/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 INGLESIDE AVE STE 1
CATONSVILLE MD
21228-1317
US

IV. Provider business mailing address

1000 INGLESIDE AVE
CATONSVILLE MD
21228-1317
US

V. Phone/Fax

Practice location:
  • Phone: 443-551-3784
  • Fax: 443-551-3801
Mailing address:
  • Phone: 443-551-3784
  • Fax: 443-551-3801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: PAULA OHIKU
Title or Position: DIRECTOR
Credential: NURSE PRACTITTIONER
Phone: 410-404-7651