Healthcare Provider Details

I. General information

NPI: 1346890027
Provider Name (Legal Business Name): CREATIVE COUNSELING CENTER OF NWA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2019
Last Update Date: 09/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 MCCLAIN RD STE 6003
BENTONVILLE AR
72712-6379
US

IV. Provider business mailing address

902 MCCLAIN RD STE 6003
BENTONVILLE AR
72712-6379
US

V. Phone/Fax

Practice location:
  • Phone: 479-257-1919
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: CHARLOTTE EVANS
Title or Position: CO OWNER
Credential: LPC
Phone: 479-257-1919