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General NPI Number Information
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NPI Number | 1366111783
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Entity Type | Organization
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Legal Business Name | CREATIVE MIND PSYCHOTHERAPY PLLC
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Dates
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Enumeration Date | 09/09/2021
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Last Update Date | 09/09/2021
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Provider Practice Location Address
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Address Line | 5035 LANGDALE WAY
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City | COLORADO SPRINGS
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State | CO
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Zip | 80906-7673
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Country | US
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Telephone | 912-610-2107
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Fax |
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Provider Business Mailing Address
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Address Line | 5035 LANGDALE WAY
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City | COLORADO SPRINGS
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State | CO
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Zip | 80906-7673
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Country | US
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Telephone | 912-610-2107
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JESSICA L WYNN
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Credential | LMFT
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Telephone | 912-610-2107
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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