Provider Demographics
NPI:1497094205
Name:CHANGING PHASES BEHAVIORAL SUPPORT, INC
Entity Type:Organization
Organization Name:CHANGING PHASES BEHAVIORAL SUPPORT, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MYA
Authorized Official - Middle Name:S
Authorized Official - Last Name:CULLINS
Authorized Official - Suffix:
Authorized Official - Credentials:LCASA
Authorized Official - Phone:336-268-6469
Mailing Address - Street 1:3655 CANTON RD
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-2690
Mailing Address - Country:US
Mailing Address - Phone:770-726-1162
Mailing Address - Fax:770-702-5966
Practice Address - Street 1:3655 CANTON RD STE 201
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066
Practice Address - Country:US
Practice Address - Phone:707-261-1627
Practice Address - Fax:707-702-5966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-14
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA25937207R00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC=========OtherFEDERAL EIN