Provider Demographics
NPI:1477917979
Name:PLACE FOR CHANGE
Entity Type:Organization
Organization Name:PLACE FOR CHANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:ASA-AD
Authorized Official - Phone:410-370-8544
Mailing Address - Street 1:117 MAPLE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-6518
Mailing Address - Country:US
Mailing Address - Phone:410-370-8544
Mailing Address - Fax:
Practice Address - Street 1:117 MAPLE RIDGE RD
Practice Address - Street 2:
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136-6518
Practice Address - Country:US
Practice Address - Phone:410-370-8544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility