=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609176205
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHANGE IS COMING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2010
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8226 MCCLELLAND PL
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22309-1833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-587-1982
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8226 MCCLELLAND PL
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22309-1833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-587-1982
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/ FOUNDER
-----------------------------------------------------
Name | MRS. NICOLE SUTHERLAND
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 703-587-1982
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305R00000X
-----------------------------------------------------
Taxonomy Name | Preferred Provider Organization
-----------------------------------------------------
License Number | 02-0814359
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 305R00000X
-----------------------------------------------------
Taxonomy Name | Preferred Provider Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------