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General NPI Number Information
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NPI Number | 1538515309
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Entity Type | Organization
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Legal Business Name | AGENT OF CHANGE, LLC
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Dates
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Enumeration Date | 05/10/2016
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Last Update Date | 05/10/2016
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Provider Practice Location Address
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Address Line | 605 POST OFFICE RD SUITE 301
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City | WALDORF
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State | MD
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Zip | 20602-1913
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Country | US
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Telephone | 240-346-0934
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Fax |
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Provider Business Mailing Address
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Address Line | 605 POST OFFICE RD SUITE 301
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City | WALDORF
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State | MD
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Zip | 20602-1913
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Country | US
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Telephone | 240-346-0934
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Fax |
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Authorized Official
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Title or Position | CLINICAL THERAPIST
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Name | MRS. BERTHA LEE WHITE
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Credential | LCSW-C
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Telephone | 240-346-0934
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 15403
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License Number State | MD
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