Healthcare Provider Details

I. General information

NPI: 1134779176
Provider Name (Legal Business Name): CREATIVE SPIRIT COUNSELING, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2019
Last Update Date: 07/25/2024
Certification Date: 02/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4675 40TH AVENUE SOUTH SUITE 120
FARGO ND
58104
US

IV. Provider business mailing address

4675 40TH AVENUE SOUTH SUITE 120
FARGO ND
58104
US

V. Phone/Fax

Practice location:
  • Phone: 701-715-8567
  • Fax: 701-540-0098
Mailing address:
  • Phone: 701-715-8567
  • Fax: 701-540-0098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1478422
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name: MRS. EMILY M JONES
Title or Position: MANAGING MEMBER
Credential: LCSW
Phone: 701-715-8567