Healthcare Provider Details

I. General information

NPI: 1831607910
Provider Name (Legal Business Name): CREATIVE JOURNEY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2018
Last Update Date: 01/28/2021
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

429 2ND ST SW STE 205
JAMESTOWN ND
58401
US

IV. Provider business mailing address

419 5TH ST NE # 14B
JAMESTOWN ND
58401-3318
US

V. Phone/Fax

Practice location:
  • Phone: 701-658-9032
  • Fax:
Mailing address:
  • Phone: 701-658-9032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. SHAULEE AHLERS IVERSON
Title or Position: COO/ADMINISTRATOR
Credential: MS OTR/L
Phone: 701-658-9032