Healthcare Provider Details

I. General information

NPI: 1609196898
Provider Name (Legal Business Name): THE CREATIVE THERAPY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2010
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 HIGHWAY 10 STE 102
ELK RIVER MN
55330-5204
US

IV. Provider business mailing address

657 MAIN ST NW STE 214
ELK RIVER MN
55330-1584
US

V. Phone/Fax

Practice location:
  • Phone: 763-274-0510
  • Fax:
Mailing address:
  • Phone: 763-274-0510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. NICOLE RENEE-HAUSER BAKER
Title or Position: CLINIC DIRECTOR
Credential: PHD, LMFT, RPT
Phone: 763-274-0510