Provider Demographics
NPI:1710133608
Name:CULTIVATING CHANGE, LLC
Entity Type:Organization
Organization Name:CULTIVATING CHANGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORGAINZER/MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:DUWANDA
Authorized Official - Middle Name:S
Authorized Official - Last Name:CONWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-458-1783
Mailing Address - Street 1:3530 S PITT ST
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27828-1884
Mailing Address - Country:US
Mailing Address - Phone:252-458-1783
Mailing Address - Fax:
Practice Address - Street 1:2109 SAINT ANDREW ST
Practice Address - Street 2:STE 18
Practice Address - City:TARBORO
Practice Address - State:NC
Practice Address - Zip Code:27886-2149
Practice Address - Country:US
Practice Address - Phone:252-458-1783
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X
NC251B00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase Management
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral Health