Provider Demographics
NPI:1427716299
Name:BRANDING ATHLETES AS LEGENDARY LEADERS
Entity type:Organization
Organization Name:BRANDING ATHLETES AS LEGENDARY LEADERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHAWNTESE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-643-3894
Mailing Address - Street 1:6617 13TH PL NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20012-2309
Mailing Address - Country:US
Mailing Address - Phone:240-643-3894
Mailing Address - Fax:
Practice Address - Street 1:6617 13TH PL NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20012-2309
Practice Address - Country:US
Practice Address - Phone:240-643-3894
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty