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General NPI Number Information
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NPI Number | 1568591782
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Entity Type | Organization
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Legal Business Name | CREATIVE ALTERNATIVES FOR PSYCHOLOGICAL GROWTH
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Dates
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Enumeration Date | 03/05/2007
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Last Update Date | 06/30/2010
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Provider Practice Location Address
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Address Line | 645 MCHENRY AVE
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City | WOODSTOCK
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State | IL
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Zip | 60098-2922
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Country | US
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Telephone | 815-245-6669
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1861
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City | WOODSTOCK
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State | IL
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Zip | 60098-1861
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Country | US
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Telephone | 815-245-6669
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Fax |
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST
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Name | DR. KELLY VINEHOUT
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Credential | PSYD
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Telephone | 815-245-6669
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071-006683
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 180-006526
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 071-006683
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License Number State | IL
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