Healthcare Provider Details

I. General information

NPI: 1053794065
Provider Name (Legal Business Name): CREATIVE CHANGE COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2015
Last Update Date: 05/15/2022
Certification Date: 05/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

423 7TH AVE SW
HICKORY NC
28602-3237
US

IV. Provider business mailing address

774 EAYRESTOWN RD SUITE 204
LUMBERTON NJ
08048-3100
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNJ

VIII. Authorized Official

Name: BERTEE THOMAS
Title or Position: PROGRAM OPERATIONS EXECUTIVE DIRECT
Credential:
Phone: 609-668-4719