Healthcare Provider Details

I. General information

NPI: 1134610991
Provider Name (Legal Business Name): ENABLING CHANGE REBUILDING COMMUNITIES EACH COUNSELING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2018
Last Update Date: 04/07/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10640 MAIN ST. SUITE 105
FAIRFAX VA
22030
US

IV. Provider business mailing address

9400 GRAND BLVD APT 1306
UPPER MARLBORO MD
20774-2646
US

V. Phone/Fax

Practice location:
  • Phone: 804-742-2858
  • Fax: 240-414-0800
Mailing address:
  • Phone: 443-219-6682
  • Fax: 240-414-0080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MS. ERICA E. NOBLE
Title or Position: CEO
Credential:
Phone: 443-219-6682