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General NPI Number Information
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NPI Number | 1962182493
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Entity Type | Organization
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Legal Business Name | INSPIRED BY CHANGE
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Dates
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Enumeration Date | 07/19/2023
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Last Update Date | 11/12/2024
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Provider Practice Location Address
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Address Line | 6490 KELMSCOT CT
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City | FAYETTEVILLE
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State | NC
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Zip | 28303-5674
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Country | US
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Telephone | 910-835-6895
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Fax |
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Provider Business Mailing Address
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Address Line | 2754 SHELLBARK RD # A
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City | DECATUR
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State | GA
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Zip | 30035-4113
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Country | US
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Telephone | 910-475-8048
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JUSTIN FENDELL GREEN
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Credential | PH.D, LCSW, LCASA
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Telephone | 910-835-6895
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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 |
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License Number State |
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