Provider Demographics
NPI:1609320340
Name:CHANGING LIVES ADULT & YOUTH SERVICES
Entity Type:Organization
Organization Name:CHANGING LIVES ADULT & YOUTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SYDNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BASKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-541-0963
Mailing Address - Street 1:9015 WOODYARD RD STE 109
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-4226
Mailing Address - Country:US
Mailing Address - Phone:240-244-2924
Mailing Address - Fax:240-244-5225
Practice Address - Street 1:9015 WOODYARD RD STE 109
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-4226
Practice Address - Country:US
Practice Address - Phone:240-244-2924
Practice Address - Fax:240-244-5225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-11
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1771251B00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1902241250Medicaid
MD1609320340Medicaid