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General NPI Number Information
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NPI Number | 1598012155
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Entity Type | Organization
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Legal Business Name | CHANGING GENERATIONAL LEGACIES,LLC
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Dates
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Enumeration Date | 08/13/2012
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Last Update Date | 08/13/2012
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Provider Practice Location Address
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Address Line | 1401 MERCANTILE LN SUITE 200-Q
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City | LARGO
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State | MD
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Zip | 20774-4301
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Country | US
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Telephone | 301-322-4141
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Fax | 301-322-9199
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Provider Business Mailing Address
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Address Line | 1401 MERCANTILE LN SUITE 200-Q
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City | LARGO
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State | MD
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Zip | 20774-4301
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Country | US
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Telephone | 301-322-4141
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Fax | 301-322-9199
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Authorized Official
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Title or Position | CEO, FOUNDER
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Name | MS. DEBRA JOYCE JOHNSON
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Credential | MS, LCPC
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Telephone | 301-322-4141
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LC3809
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License Number State | MD
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