Provider Demographics
NPI:1538544424
Name:CHANGING FAMLIES & LIVES
Entity type:Organization
Organization Name:CHANGING FAMLIES & LIVES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHALEEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:GASTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:980-213-8589
Mailing Address - Street 1:8517 GALENA VIEW DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-7179
Mailing Address - Country:US
Mailing Address - Phone:980-213-8589
Mailing Address - Fax:
Practice Address - Street 1:8517 GALENA VIEW DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-7179
Practice Address - Country:US
Practice Address - Phone:980-213-8589
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-21
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No302R00000XManaged Care OrganizationsHealth Maintenance OrganizationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC47-4580700Medicaid