MEDICARE: CREATIVE LIFE 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	1041C0700X	Clinical Social Worker	6985612-3501	UT

General Provider Information

NPI Number	:	1699051219
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CREATIVE LIFE COUNSELING

Provider Business Mailing Address
First Line	:	925 E 900 S
Second Line	:	#42
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-1401
Country	:	US
Telephone Number	:	801-657-0897
Fax Number	:	801-363-6564

Provider Business Practice Location Address
First Line	:	925 E 900 S
Second Line	:	SUITE # 42
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-1401
Country	:	US
Telephone Number	:	801-657-0897
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	ASHLEY SUTHERLAND
Credential	:	LCSW
Telephone Number	:	502-741-6065

Provider Enumeration Date	:	10/26/2011
Last Update Date	:	10/26/2011

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