Healthcare Provider Details

I. General information

NPI: 1477138253
Provider Name (Legal Business Name): CREATIVE GROWTH THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2021
Last Update Date: 09/17/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3584 W OUTER DR
DETROIT MI
48221-1662
US

IV. Provider business mailing address

3584 W OUTER DR
DETROIT MI
48221-1662
US

V. Phone/Fax

Practice location:
  • Phone: 248-396-4602
  • Fax:
Mailing address:
  • Phone: 248-396-4602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: JENNA I DEBRYN
Title or Position: OWNER
Credential: MA, LPC, ATR
Phone: 504-407-1713