Healthcare Provider Details

I. General information

NPI: 1447978473
Provider Name (Legal Business Name): CREATIVE CHANGE COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2022
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2840 ROLLING FORK WAY
GLENWOOD MD
21738-9746
US

IV. Provider business mailing address

668 MAIN ST
LUMBERTON NJ
08048-5016
US

V. Phone/Fax

Practice location:
  • Phone: 609-668-4719
  • Fax: 609-667-7944
Mailing address:
  • Phone: 609-668-4719
  • Fax: 609-667-7944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. BERTEE THOMAS JR.
Title or Position: CEO
Credential: PSY. D.
Phone: 609-667-7353