Provider Demographics
NPI:1760102685
Name:CHANGE REACTION BALTIMORE
Entity Type:Organization
Organization Name:CHANGE REACTION BALTIMORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVON
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-204-3181
Mailing Address - Street 1:1111 PARK AVE STE L111
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-5695
Mailing Address - Country:US
Mailing Address - Phone:443-204-3181
Mailing Address - Fax:
Practice Address - Street 1:1111 PARK AVE STE L111
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-5695
Practice Address - Country:US
Practice Address - Phone:443-204-3181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-31
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health