Provider Demographics
NPI:1275201758
Name:CHANGE REACTION
Entity Type:Organization
Organization Name:CHANGE REACTION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROGRAM MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:M
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-864-0919
Mailing Address - Street 1:4404 QUEENSBURY RD STE 105
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:MD
Mailing Address - Zip Code:20737-1074
Mailing Address - Country:US
Mailing Address - Phone:240-432-7659
Mailing Address - Fax:301-864-1301
Practice Address - Street 1:4404 QUEENSBURY RD STE 105
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:MD
Practice Address - Zip Code:20737-1074
Practice Address - Country:US
Practice Address - Phone:240-432-7659
Practice Address - Fax:301-864-1301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health