MEDICARE: UPWARD CHANGE HEALTH SERVICES

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	P010729	NC

General Provider Information

NPI Number	:	1912449158
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UPWARD CHANGE HEALTH SERVICES

Provider Business Mailing Address
First Line	:	2003 E NC HIGHWAY 54
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27713
Country	:	US
Telephone Number	:	919-682-5300
Fax Number	:

Provider Business Practice Location Address
First Line	:	2003 E NC HIGHWAY 54
Second Line	:	SUITE C
City	:	DURHAM
State	:	NC
Zip	:	27713-2482
Country	:	US
Telephone Number	:	919-682-5300
Fax Number	:

Authorized Official
Title or Position	:	TEAM LEAD II-H
Name	:	MR. ERVIN DAVIS JR.
Credential	:	LCSW-A
Telephone Number	:	919-685-2425

Provider Enumeration Date	:	11/04/2016
Last Update Date	:	11/04/2016

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27713-2482

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1306083688 — UPWARD CHANGE HEALTH SERVICES, LLC
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27713-2482

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1700250313 — DARIA C MALLARD
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1518412469 — MRS. PORTIA GANPOT MSW, LCSWA
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Directions to “UPWARD CHANGE HEALTH SERVICES ” Practice Location

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