Healthcare Provider Details

I. General information

NPI: 1275305278
Provider Name (Legal Business Name): CREATIVE HEALING EXPRESSIVE ARTS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2023
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 E CHESTNUT ST
BLOOMINGTON IL
61701-3009
US

IV. Provider business mailing address

200 W MONROE ST STE 23
BLOOMINGTON IL
61701-3955
US

V. Phone/Fax

Practice location:
  • Phone: 309-490-3060
  • Fax: 309-490-3060
Mailing address:
  • Phone: 309-287-0610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KARLI JOHNSON
Title or Position: FOUNDER
Credential:
Phone: 309-287-0610