Healthcare Provider Details

I. General information

NPI: 1124477963
Provider Name (Legal Business Name): CO-CREATIVE COACHING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2016
Last Update Date: 06/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 LINTON BLVD 203-A
DELRAY BEACH FL
33444-8167
US

IV. Provider business mailing address

13900 JOG RD STE 262
DELRAY BEACH FL
33446-5905
US

V. Phone/Fax

Practice location:
  • Phone: 561-285-2052
  • Fax:
Mailing address:
  • Phone: 561-285-2052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberSW13546
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSW13546
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberSW13546
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License NumberSW13546
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberSW13546
License Number StateFL

VIII. Authorized Official

Name: MS. JANUS MONCUR
Title or Position: MMGR/OWNER
Credential: LCSW
Phone: 561-285-2052