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General NPI Number Information
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NPI Number | 1003004508
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Entity Type | Organization
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Legal Business Name | KREATIVE COUNSELING ENRICHMENT SERVICES, LLC
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Dates
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Enumeration Date | 10/09/2007
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Last Update Date | 10/09/2007
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Provider Practice Location Address
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Address Line | 2110 N BELTLINE BLVD
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City | COLUMBIA
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State | SC
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Zip | 29204-3999
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Country | US
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Telephone | 803-261-1621
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 4493
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City | COLUMBIA
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State | SC
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Zip | 29240-4493
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PROFESSIONAL COUNSELOR
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Name | MS. CRYSTAL M RUSSELL
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Credential | LPC
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Telephone | 803-261-1621
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 4739
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License Number State | SC
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