Provider Demographics
NPI:1891317657
Name:CHANGING LIVES THERAPEUTIC SERVICE, LLC
Entity Type:Organization
Organization Name:CHANGING LIVES THERAPEUTIC SERVICE, LLC
Other - Org Name:CHANGING LIVES THERAPEUTIC SERVICE,LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CEMETRIUS
Authorized Official - Middle Name:
Authorized Official - Last Name:ROLLE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:980-833-1121
Mailing Address - Street 1:8825 UNIVERSITY EAST DR STE 200
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-4395
Mailing Address - Country:US
Mailing Address - Phone:980-833-1121
Mailing Address - Fax:
Practice Address - Street 1:413 MOUNT CROSS RD STE 102
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540-4089
Practice Address - Country:US
Practice Address - Phone:888-388-8726
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-14
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1295117760Medicaid
NC1922582998Medicaid