Provider Demographics
NPI:1104144682
Name:MENTORING FOR CHANGE, INC
Entity type:Organization
Organization Name:MENTORING FOR CHANGE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHD
Authorized Official - Prefix:DR
Authorized Official - First Name:DALTON
Authorized Official - Middle Name:STEPHON
Authorized Official - Last Name:KORNEGAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-714-2145
Mailing Address - Street 1:1206 EVANS ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-4102
Mailing Address - Country:US
Mailing Address - Phone:252-695-2004
Mailing Address - Fax:252-695-2005
Practice Address - Street 1:211 W 14TH ST
Practice Address - Street 2:SUITE D
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-4081
Practice Address - Country:US
Practice Address - Phone:252-695-2004
Practice Address - Fax:252-695-2005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-10
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services