Healthcare Provider Details

I. General information

NPI: 1275201758
Provider Name (Legal Business Name): CHANGE REACTION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2021
Last Update Date: 08/31/2021
Certification Date: 07/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4404 QUEENSBURY RD STE 105
RIVERDALE MD
20737-1074
US

IV. Provider business mailing address

4404 QUEENSBURY RD STE 105
RIVERDALE MD
20737-1074
US

V. Phone/Fax

Practice location:
  • Phone: 240-432-7659
  • Fax: 301-864-1301
Mailing address:
  • Phone: 240-432-7659
  • Fax: 301-864-1301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. KIMBERLY M GREEN
Title or Position: OWNER/PROGRAM MANAGER
Credential:
Phone: 301-864-0919