MEDICARE: RADICAL LIFE CHANGES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1295681682
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RADICAL LIFE CHANGES LLC

Provider Business Mailing Address
First Line	:	11777 NATIONALS LN
Second Line	:
City	:	WALDORF
State	:	MD
Zip	:	20602-3274
Country	:	US
Telephone Number	:	301-456-5058
Fax Number	:

Provider Business Practice Location Address
First Line	:	11777 NATIONALS LN
Second Line	:
City	:	WALDORF
State	:	MD
Zip	:	20602-3274
Country	:	US
Telephone Number	:	301-456-5058
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	VALENCIA BONNER LEWIS
Credential	:	LCSW
Telephone Number	:	301-456-5058

Provider Enumeration Date	:	03/07/2026
Last Update Date	:	03/07/2026

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