Healthcare Provider Details

I. General information

NPI: 1346488491
Provider Name (Legal Business Name): CREATIVE CHANGE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2009
Last Update Date: 01/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5331 COMMERCIAL WAY STE 212
SPRING HILL FL
34606-1426
US

IV. Provider business mailing address

5331 COMMERCIAL WAY STE 212
SPRING HILL FL
34606-1426
US

V. Phone/Fax

Practice location:
  • Phone: 352-597-0969
  • Fax: 352-597-6853
Mailing address:
  • Phone: 352-597-0969
  • Fax: 352-597-6853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH2746
License Number StateFL

VIII. Authorized Official

Name: MR. TED ROBERT PEARSON
Title or Position: PRESIDENT
Credential: M.A., LMHC
Phone: 352-597-0969