MEDICARE: TIME FOR CHANGE

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	251S00000X	Community/Behavioral Health Agency	PRC14577	DC

General Provider Information

NPI Number	:	1518319573
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIME FOR CHANGE

Provider Business Mailing Address
First Line	:	1929 VALLEY TER SE
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20032-4627
Country	:	US
Telephone Number	:	202-768-8454
Fax Number	:

Provider Business Practice Location Address
First Line	:	1651 TULIP AVE
Second Line	:
City	:	DISTRICT HEIGHTS
State	:	MD
Zip	:	20747-2622
Country	:	US
Telephone Number	:	202-403-9206
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MRS. TONYA RIDLEY
Credential	:	LPC CRC
Telephone Number	:	202-768-8454

Provider Enumeration Date	:	07/01/2016
Last Update Date	:	07/01/2016

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