Healthcare Provider Details

I. General information

NPI: 1154488773
Provider Name (Legal Business Name): CREATIVE COUNSELING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1956 OHIO AVE
CONNERSVILLE IN
47331-2858
US

IV. Provider business mailing address

1956 OHIO AVE
CONNERSVILLE IN
47331-2858
US

V. Phone/Fax

Practice location:
  • Phone: 765-827-5610
  • Fax: 765-825-9440
Mailing address:
  • Phone: 765-827-5610
  • Fax: 765-825-9440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34004224A
License Number StateIN

VIII. Authorized Official

Name: MRS. DEBRA K. SHAIN
Title or Position: CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 765-827-5610