MEDICARE: CREATIVE CHANGE COUNSELING, INC.

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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1407432321
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CREATIVE CHANGE COUNSELING, INC.

Provider Business Mailing Address
First Line	:	774 EAYRESTOWN RD STE 204
Second Line	:
City	:	LUMBERTON
State	:	NJ
Zip	:	08048-3100
Country	:	US
Telephone Number	:	609-668-4719
Fax Number	:	609-667-7944

Provider Business Practice Location Address
First Line	:	322 E 5TH ST
Second Line	:
City	:	LAKEWOOD
State	:	NJ
Zip	:	08701-3415
Country	:	US
Telephone Number	:	609-668-4719
Fax Number	:	609-667-7944

Authorized Official
Title or Position	:	CEO
Name	:	BERTEE THOMAS JR.
Credential	:	PSY.D.
Telephone Number	:	609-668-4719

Provider Enumeration Date	:	03/22/2021
Last Update Date	:	03/22/2021

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