MEDICARE: CHANGING LIVES ADULT & YOUTH SERVICES

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QR0400X	Rehabilitation Clinic/Center
2	251B00000X	Case Management Agency
3	251S00000X	Community/Behavioral Health Agency
4	261QM0855X	Adolescent and Children Mental Health Clinic/Center
5	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1902241250
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHANGING LIVES ADULT & YOUTH SERVICES

Provider Business Mailing Address
First Line	:	4810 SAINT BARNABAS RD STE 203
Second Line	:
City	:	TEMPLE HILLS
State	:	MD
Zip	:	20748-4604
Country	:	US
Telephone Number	:	301-541-0963
Fax Number	:

Provider Business Practice Location Address
First Line	:	4810 SAINT BARNABAS RD STE 203
Second Line	:
City	:	TEMPLE HILLS
State	:	MD
Zip	:	20748-4604
Country	:	US
Telephone Number	:	202-431-5576
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. SYDNEY BASKINS
Credential	:	B.A.
Telephone Number	:	301-541-0963

Provider Enumeration Date	:	04/30/2013
Last Update Date	:	09/10/2019

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