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General NPI Number Information
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NPI Number | 1316460728
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Entity Type | Organization
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Legal Business Name | CREATIVE ROOTS COUNSELING, LLC
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Dates
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Enumeration Date | 07/18/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 4305 N LINCOLN AVE STE K
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City | CHICAGO
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State | IL
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Zip | 60618-1807
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Country | US
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Telephone | 773-466-4527
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Fax |
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Provider Business Mailing Address
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Address Line | 4305 N LINCOLN AVE STE K
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City | CHICAGO
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State | IL
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Zip | 60618-1807
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Country | US
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Telephone | 773-466-4527
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Fax |
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Authorized Official
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Title or Position | PSYCHOTHERAPIST
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Name | KRISTINA VOGT
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Credential | LCPC, ATR
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Telephone | 773-466-4527
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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 | 180008745
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License Number State | IL
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