MEDICARE: CREATIVE RESTORATION AND GUIDANCE

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	10017	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	19GVD	OTHER	NC	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1891226015
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CREATIVE RESTORATION AND GUIDANCE

Provider Business Mailing Address
First Line	:	PO BOX 220
Second Line	:
City	:	ROLESVILLE
State	:	NC
Zip	:	27571-0220
Country	:	US
Telephone Number	:	919-824-7789
Fax Number	:

Provider Business Practice Location Address
First Line	:	8303 PLANO CT
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27616-6640
Country	:	US
Telephone Number	:	919-824-7789
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MISS CHRISTISHAWN GORE
Credential	:	MA LPC, NCC, LCAS-A
Telephone Number	:	919-824-7789

Provider Enumeration Date	:	03/21/2017
Last Update Date	:	03/21/2017

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