Healthcare Provider Details

I. General information

NPI: 1437209681
Provider Name (Legal Business Name): CENTER FOR CREATIVE CHANGE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 02/16/2021
Certification Date: 02/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NORTHLAND ST
FISHERS IN
46038-1147
US

IV. Provider business mailing address

100 NORTHLAND ST
FISHERS IN
46038-1147
US

V. Phone/Fax

Practice location:
  • Phone: 317-845-5133
  • Fax: 317-845-5133
Mailing address:
  • Phone: 317-845-5133
  • Fax: 317-845-5133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34002187
License Number StateIN

VIII. Authorized Official

Name: MS. KAY MATTINGLY LANGLOIS
Title or Position: PRESIDENT
Credential: LCSW, LMFT
Phone: 317-845-5133