Healthcare Provider Details

I. General information

NPI: 1700313780
Provider Name (Legal Business Name): KINGDOM CREATIVE COUNSELING PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2017
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 REVOLUTION MILL DR STE 2
GREENSBORO NC
27405-5053
US

IV. Provider business mailing address

PO BOX 14222
GREENSBORO NC
27415-4222
US

V. Phone/Fax

Practice location:
  • Phone: 336-543-0159
  • Fax: 336-663-2906
Mailing address:
  • Phone: 336-543-0159
  • Fax: 336-663-2906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC007049
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC007049
License Number StateNC

VIII. Authorized Official

Name: SAMARIA M COLBERT
Title or Position: OWNER
Credential: LCSW
Phone: 336-543-0159