Healthcare Provider Details

I. General information

NPI: 1740166495
Provider Name (Legal Business Name): CREATIVE ROOTS COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2025
Last Update Date: 08/15/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N9450 MOHAWK RD STE 113
THERESA WI
53091-9770
US

IV. Provider business mailing address

W5175 COUNTY ROAD Y
FOND DU LAC WI
54937-7783
US

V. Phone/Fax

Practice location:
  • Phone: 920-948-3706
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: AMBER BROWN
Title or Position: OWNER, MENTAL HEALTH THERAPIST
Credential: MS, LPC, ATR
Phone: 920-948-3706