Healthcare Provider Details

I. General information

NPI: 1124480926
Provider Name (Legal Business Name): CREATIVE COUNSELING AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 MARCHWOOD RD SUITE 2A-8
EXTON PA
19341-1835
US

IV. Provider business mailing address

905 CHARLESTON GRN
MALVERN PA
19355-2457
US

V. Phone/Fax

Practice location:
  • Phone: 484-571-8919
  • Fax:
Mailing address:
  • Phone: 484-571-8919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberCW 015583
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberPC007162
License Number StatePA

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MR. CHRISTOPHER J CARBO
Title or Position: CO-OWNER
Credential: LPC
Phone: 484-571-8919