MEDICARE: CREATIVE INSIGHT COUNSELING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1326512039
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CREATIVE INSIGHT COUNSELING

Provider Business Mailing Address
First Line	:	1114 WARDEN ST
Second Line	:
City	:	BENBROOK
State	:	TX
Zip	:	76126-3526
Country	:	US
Telephone Number	:	206-226-4249
Fax Number	:

Provider Business Practice Location Address
First Line	:	3309 WINTHROP AVE STE 76
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-5600
Country	:	US
Telephone Number	:	206-226-4249
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ROSANA E MINA-MEZA
Credential	:	LPC
Telephone Number	:	206-226-4249

Provider Enumeration Date	:	01/15/2019
Last Update Date	:	01/15/2019

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