Provider Demographics
NPI:1710491287
Name:CHANGING LIVES AT HOME MENTAL HEALTH CORPORATION
Entity Type:Organization
Organization Name:CHANGING LIVES AT HOME MENTAL HEALTH CORPORATION
Other - Org Name:CHANGING LIVES HOME SUD
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LATRILL
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYANT-BASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-869-2600
Mailing Address - Street 1:202 GLENN ELLEN CIR
Mailing Address - Street 2:
Mailing Address - City:PIKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-1028
Mailing Address - Country:US
Mailing Address - Phone:443-463-9523
Mailing Address - Fax:
Practice Address - Street 1:4805 GARRISON BLVD
Practice Address - Street 2:1ST FLOOR AND SUITE 200
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5695
Practice Address - Country:US
Practice Address - Phone:443-869-2600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-20
Last Update Date:2023-08-02
Deactivation Date:2023-05-22
Deactivation Code:
Reactivation Date:2023-07-10
Provider Licenses
StateLicense IDTaxonomies
MD251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health