MEDICARE: CHANGING FAZES YOUTH & FAMILY SERVICES, INC.

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

General Provider Information

NPI Number	:	1811129299
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHANGING FAZES YOUTH & FAMILY SERVICES, INC.

Provider Business Mailing Address
First Line	:	2025 E MAIN ST STE 212
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23223-7073
Country	:	US
Telephone Number	:	804-344-3730
Fax Number	:	804-344-3731

Provider Business Practice Location Address
First Line	:	2025 E MAIN ST STE 212
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23223-7073
Country	:	US
Telephone Number	:	804-344-3730
Fax Number	:	804-344-3731

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	EBONY SAULS
Credential	:
Telephone Number	:	804-344-3730

Provider Enumeration Date	:	08/18/2009
Last Update Date	:	08/18/2009

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