Healthcare Provider Details

I. General information

NPI: 1245656776
Provider Name (Legal Business Name): CROSSWALK TO CHANGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2014
Last Update Date: 03/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12676 NATIONAL PIKE
GRANTSVILLE MD
21536-3320
US

IV. Provider business mailing address

12676 NATIONAL PIKE
GRANTSVILLE MD
21536-3320
US

V. Phone/Fax

Practice location:
  • Phone: 301-895-8087
  • Fax: 301-895-8097
Mailing address:
  • Phone: 301-895-8087
  • Fax: 301-895-8097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16149
License Number StateMD

VIII. Authorized Official

Name: MRS. VICKY LYNN ZANG
Title or Position: PRESIDENT
Credential: LCSW-C
Phone: 301-895-8087