Healthcare Provider Details

I. General information

NPI: 1811057045
Provider Name (Legal Business Name): CHANGING PHASES BEHAVIORAL SUPPORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 03/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 CLEMMONS ST
GREENSBORO NC
27406-2870
US

IV. Provider business mailing address

338 N ELM ST SUITE 215
GREENSBORO NC
27401-2177
US

V. Phone/Fax

Practice location:
  • Phone: 336-333-2542
  • Fax: 336-333-2858
Mailing address:
  • Phone: 336-333-2542
  • Fax: 336-333-2858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberMHL-041-794
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberMHL-041-894
License Number StateNC

VIII. Authorized Official

Name: MR. QUINTEN CULLINS
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 336-333-2542