Healthcare Provider Details

I. General information

NPI: 1154382265
Provider Name (Legal Business Name): CREATIVE COUNSELING PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 11/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 WAYMONT CT SUITE 111
LAKE MARY FL
32746-3593
US

IV. Provider business mailing address

205 WAYMONT COURT SUITE 111
LAKE MARY FL
32746-3549
US

V. Phone/Fax

Practice location:
  • Phone: 407-688-1770
  • Fax: 407-688-7205
Mailing address:
  • Phone: 407-688-1770
  • Fax: 407-688-7205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberMH7317
License Number StateFL

VIII. Authorized Official

Name: MICHELLE ANN SALOMON
Title or Position: PRES
Credential: LMHC
Phone: 407-688-1770