Healthcare Provider Details

I. General information

NPI: 1184953929
Provider Name (Legal Business Name): CREATIVE COUNSELING CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2009
Last Update Date: 12/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 S LINCOLN AVE
O FALLON IL
62269-2665
US

IV. Provider business mailing address

PO BOX 701
O FALLON IL
62269-0701
US

V. Phone/Fax

Practice location:
  • Phone: 618-632-0701
  • Fax: 618-222-1370
Mailing address:
  • Phone: 618-632-0701
  • Fax: 618-222-1370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number166000342
License Number StateIL

VIII. Authorized Official

Name: DR. LINDA J COWDEN
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 618-632-0701