Provider Demographics
NPI:1538446679
Name:EMPOWERING YOUTH FOR POSITIVE CHANGE
Entity type:Organization
Organization Name:EMPOWERING YOUTH FOR POSITIVE CHANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TOWANDA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:HICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-908-6088
Mailing Address - Street 1:PO BOX 1201
Mailing Address - Street 2:
Mailing Address - City:TAPPAHANNOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22560-1201
Mailing Address - Country:US
Mailing Address - Phone:804-443-4428
Mailing Address - Fax:804-443-4558
Practice Address - Street 1:11555 MEDLOCK BRIDGE RD STE 100
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-3200
Practice Address - Country:US
Practice Address - Phone:404-341-6008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1504251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health