Healthcare Provider Details

I. General information

NPI: 1760515498
Provider Name (Legal Business Name): CREATIVE CHANGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 CLARKSON EXECUTIVE PARK
ELLISVILLE MO
63011-2176
US

IV. Provider business mailing address

177 CLARKSON EXECUTIVE PARK
ELLISVILLE MO
63011-2176
US

V. Phone/Fax

Practice location:
  • Phone: 314-962-7788
  • Fax:
Mailing address:
  • Phone: 314-962-7788
  • Fax: 314-962-4158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: RHONDA STEWART
Title or Position: BILLING MANAGER
Credential:
Phone: 636-893-8949