Provider Demographics
NPI:1407035918
Name:CHANGE LANES YOUTH SUPPORT SERVICES
Entity Type:Organization
Organization Name:CHANGE LANES YOUTH SUPPORT SERVICES
Other - Org Name:CHANGE LANES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:HUNTER-SPEARS
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CATC
Authorized Official - Phone:661-948-2555
Mailing Address - Street 1:45118 13TH STREET WEST
Mailing Address - Street 2:UNIT 1D
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-2156
Mailing Address - Country:US
Mailing Address - Phone:661-948-2555
Mailing Address - Fax:661-878-9130
Practice Address - Street 1:45118 13TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2156
Practice Address - Country:US
Practice Address - Phone:661-948-5555
Practice Address - Fax:661-878-9130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2021-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10007140251S00000X, 252Y00000X
CA10023326305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No252Y00000XAgenciesEarly Intervention Provider Agency
No305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1952597627Medicaid
CA1669948832Medicaid
CA1750686598Medicaid
CA197467Medicaid