Healthcare Provider Details

I. General information

NPI: 1043377278
Provider Name (Legal Business Name): CREATIVE LIVING ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 VANCE AVE
KANNAPOLIS NC
28081-4339
US

IV. Provider business mailing address

1001 E WT HARRIS BLVD SUITE P-317
CHARLOTTE NC
28213-4104
US

V. Phone/Fax

Practice location:
  • Phone: 704-788-9184
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2296
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number526
License Number StateNC

VIII. Authorized Official

Name: DR. GLEN REDIEHS
Title or Position: SENIOR ASSOCIATE
Credential: PH.D.
Phone: 704-788-9184