Healthcare Provider Details

I. General information

NPI: 1790273522
Provider Name (Legal Business Name): ANEW INSPIRED CHANGE ORGANIZATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 MERCANTILE LN STE 246
UPPER MARLBORO MD
20774-5353
US

IV. Provider business mailing address

1400 MERCANTILE LN STE 246
UPPER MARLBORO MD
20774-5353
US

V. Phone/Fax

Practice location:
  • Phone: 301-971-2639
  • Fax: 301-386-5262
Mailing address:
  • Phone: 301-971-2639
  • Fax: 301-386-5262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number StateMD

VIII. Authorized Official

Name: PORSHIA EVERETT
Title or Position: DIRECTOR
Credential:
Phone: 301-971-2639