Healthcare Provider Details

I. General information

NPI: 1386068617
Provider Name (Legal Business Name): CREATIVE CHANGE COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2014
Last Update Date: 02/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S TOBIN ST STE A
RENTON WA
98057-5338
US

IV. Provider business mailing address

PO BOX 4158
RENTON WA
98057-4158
US

V. Phone/Fax

Practice location:
  • Phone: 425-255-5526
  • Fax: 425-255-5523
Mailing address:
  • Phone: 425-255-5526
  • Fax: 425-255-5523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCL60152004
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberCL60152004
License Number StateWA

VIII. Authorized Official

Name: KATIE WILSON
Title or Position: ADMIN ASST
Credential:
Phone: 425-255-5526