=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497585129
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CREATE SPACE COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2024
-----------------------------------------------------
Last Update Date | 08/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 610 N BUCHANAN ST
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72205-3208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-590-6072
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 610 N BUCHANAN ST
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72205-3208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-590-6072
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | ERIN LEA LORENZEN
-----------------------------------------------------
Credential | LPC, LMHC
-----------------------------------------------------
Telephone | 501-590-6072
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------