Provider Demographics
NPI:1598012155
Name:CHANGING GENERATIONAL LEGACIES,LLC
Entity Type:Organization
Organization Name:CHANGING GENERATIONAL LEGACIES,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, FOUNDER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:JOYCE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LCPC
Authorized Official - Phone:301-322-4141
Mailing Address - Street 1:1401 MERCANTILE LN
Mailing Address - Street 2:SUITE 200-Q
Mailing Address - City:LARGO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-4301
Mailing Address - Country:US
Mailing Address - Phone:301-322-4141
Mailing Address - Fax:301-322-9199
Practice Address - Street 1:1401 MERCANTILE LN
Practice Address - Street 2:SUITE 200-Q
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-4301
Practice Address - Country:US
Practice Address - Phone:301-322-4141
Practice Address - Fax:301-322-9199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-13
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC3809101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD040457800Medicaid