Healthcare Provider Details

I. General information

NPI: 1710617931
Provider Name (Legal Business Name): CREEKSIDE COUNSELING AND WELLNESS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2022
Last Update Date: 06/11/2022
Certification Date: 06/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 CONCORD PIKE STE 54
WILMINGTON DE
19803-3630
US

IV. Provider business mailing address

318 N DILLWYN RD
NEWARK DE
19711-5505
US

V. Phone/Fax

Practice location:
  • Phone: 302-562-7953
  • Fax:
Mailing address:
  • Phone: 302-562-7953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: GRETCHEN MAHONEY
Title or Position: PROFESSIONAL COUNSELOR
Credential: LCPC, LPCMH
Phone: 302-562-7953