Healthcare Provider Details

I. General information

NPI: 1053834465
Provider Name (Legal Business Name): CREATIVE CONNECTIONS PSYCHOTHERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2017
Last Update Date: 07/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 SANDY CREEK RD
THORNTON WV
26440-7614
US

IV. Provider business mailing address

260 JACK ACRES RD
BUCKHANNON WV
26201-6506
US

V. Phone/Fax

Practice location:
  • Phone: 304-460-8151
  • Fax:
Mailing address:
  • Phone: 304-460-8151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberDP00943683
License Number StateWV

VIII. Authorized Official

Name: SARAH MICHELLE LONG
Title or Position: OWNER / PSYCHOTHERAPIST
Credential: MSW, LICSW
Phone: 304-460-8151