Provider Demographics
NPI:1740611623
Name:CHANGING LIVES AT HOME, INC. MENTAL HEALTH
Entity Type:Organization
Organization Name:CHANGING LIVES AT HOME, INC. MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LATRILL
Authorized Official - Middle Name:WAIZETTE
Authorized Official - Last Name:BRYANT-BASS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:443-463-9523
Mailing Address - Street 1:3606 BELLE AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-6102
Mailing Address - Country:US
Mailing Address - Phone:443-463-9523
Mailing Address - Fax:
Practice Address - Street 1:4805 GARRISON BLVD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5695
Practice Address - Country:US
Practice Address - Phone:443-463-9523
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-03
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health