Provider Demographics
NPI:1093458051
Name:CULTIVATING CHANGE
Entity Type:Organization
Organization Name:CULTIVATING CHANGE
Other - Org Name:CULTIVATING CHANGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DELORA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-493-3372
Mailing Address - Street 1:2512 N. CHARLES STREET
Mailing Address - Street 2:1ST FLOOR/B
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-4645
Mailing Address - Country:US
Mailing Address - Phone:410-493-3372
Mailing Address - Fax:
Practice Address - Street 1:2512 N. CHARLES STREET
Practice Address - Street 2:1ST FLOOR/B
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-4645
Practice Address - Country:US
Practice Address - Phone:410-493-3372
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-18
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1558019489Medicaid