Provider Demographics
NPI:1902241250
Name:CHANGING LIVES ADULT & YOUTH SERVICES
Entity Type:Organization
Organization Name:CHANGING LIVES ADULT & YOUTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SYDNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BASKINS
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:301-541-0963
Mailing Address - Street 1:4810 SAINT BARNABAS RD STE 203
Mailing Address - Street 2:
Mailing Address - City:TEMPLE HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20748-4604
Mailing Address - Country:US
Mailing Address - Phone:301-541-0963
Mailing Address - Fax:
Practice Address - Street 1:4810 SAINT BARNABAS RD STE 203
Practice Address - Street 2:
Practice Address - City:TEMPLE HILLS
Practice Address - State:MD
Practice Address - Zip Code:20748-4604
Practice Address - Country:US
Practice Address - Phone:202-431-5576
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-30
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1902241250Medicaid
MD1609320340Medicaid