Healthcare Provider Details

I. General information

NPI: 1598999898
Provider Name (Legal Business Name): CENTER FOR CREATIVE STUDIES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2009
Last Update Date: 05/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2741 INDIAN SCHOOL RD NE
ALBUQUERQUE NM
87106-2653
US

IV. Provider business mailing address

14109 GRAND AVE NE
ALBUQUERQUE NM
87123-1802
US

V. Phone/Fax

Practice location:
  • Phone: 505-255-8682
  • Fax: 505-255-7890
Mailing address:
  • Phone: 505-255-8682
  • Fax: 505-255-7890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0085781
License Number StateNM

VIII. Authorized Official

Name: MS. CHRISTY TACKWELL
Title or Position: PRESIDENT
Credential: LPCC, LPAT
Phone: 505-255-8682