Provider Demographics
NPI:1811057045
Name:CHANGING PHASES BEHAVIORAL SUPPORT
Entity type:Organization
Organization Name:CHANGING PHASES BEHAVIORAL SUPPORT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:QUINTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CULLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-333-2542
Mailing Address - Street 1:338 N ELM ST
Mailing Address - Street 2:SUITE 215
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-2177
Mailing Address - Country:US
Mailing Address - Phone:336-333-2542
Mailing Address - Fax:336-333-2858
Practice Address - Street 1:1609 CLEMMONS ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-2870
Practice Address - Country:US
Practice Address - Phone:336-333-2542
Practice Address - Fax:336-333-2858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-041-894322D00000X
251S00000X
NCMHL-041-794322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6604413Medicaid
NC8301765Medicaid
NC6006908Medicaid
NC8301765GMedicaid