=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013430479
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CREATE HEALING COUNSELING SERVICES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2017
-----------------------------------------------------
Last Update Date | 06/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1501 N UNIVERSITY AVE STE 700
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72207-5297
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-940-6135
-----------------------------------------------------
Fax | 844-235-2943
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 CHERRY CREST CV
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72211-5437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-940-6135
-----------------------------------------------------
Fax | 844-235-2943
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | STASIA LYN MYERS
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 501-940-6135
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 2011C
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------