Healthcare Provider Details

I. General information

NPI: 1407222706
Provider Name (Legal Business Name): CREATIVE COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2015
Last Update Date: 08/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 STRATFORD CT SUITE #170
WINSTON SALEM NC
27103-1836
US

IV. Provider business mailing address

163 STRATFORD CT SUITE #170
WINSTON SALEM NC
27103-1836
US

V. Phone/Fax

Practice location:
  • Phone: 336-448-4123
  • Fax: 336-436-9123
Mailing address:
  • Phone: 336-448-4123
  • Fax: 336-436-9123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number3028-A
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8040
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number8040
License Number StateNC

VIII. Authorized Official

Name: MRS. SONYA RENEE OGLESBY
Title or Position: CEO
Credential: LPC, NCC, LCAS-A
Phone: 336-830-4765