Provider Demographics
NPI:1538515309
Name:AGENT OF CHANGE, LLC
Entity Type:Organization
Organization Name:AGENT OF CHANGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:BERTHA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:240-346-0934
Mailing Address - Street 1:605 POST OFFICE RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-1913
Mailing Address - Country:US
Mailing Address - Phone:240-346-0934
Mailing Address - Fax:
Practice Address - Street 1:605 POST OFFICE RD
Practice Address - Street 2:SUITE 301
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-1913
Practice Address - Country:US
Practice Address - Phone:240-346-0934
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD154031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty