Healthcare Provider Details

I. General information

NPI: 1346762622
Provider Name (Legal Business Name): CREATIVE COUNSELING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2017
Last Update Date: 01/05/2020
Certification Date: 01/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 WATERLOO LN
GARDNERVILLE NV
89410-7403
US

IV. Provider business mailing address

1255 WATERLOO LN
GARDNERVILLE NV
89410-7403
US

V. Phone/Fax

Practice location:
  • Phone: 775-671-5528
  • Fax:
Mailing address:
  • Phone: 775-671-5528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: SHANA STIRTON
Title or Position: OWNER
Credential: MS, CPC-INTERN
Phone: 775-671-5528