Healthcare Provider Details

I. General information

NPI: 1225484348
Provider Name (Legal Business Name): LOUISA CREATIVE COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2016
Last Update Date: 02/04/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 MINERAL AVE # 192
MINERAL VA
23117-4049
US

IV. Provider business mailing address

PO BOX 192
MINERAL VA
23117-0192
US

V. Phone/Fax

Practice location:
  • Phone: 540-259-3646
  • Fax: 540-259-3647
Mailing address:
  • Phone: 540-604-3267
  • Fax: 844-480-1755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number0701006594
License Number StateVA

VIII. Authorized Official

Name: KRISTY BAZZANELLA
Title or Position: OWNER
Credential: LPC, RPT, CCTP
Phone: 540-604-3267