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General NPI Number Information
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NPI Number | 1619201746
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Entity Type | Organization
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Legal Business Name | CENTER FOR CREATIVE CHANGE
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Dates
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Enumeration Date | 09/22/2009
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Last Update Date | 09/22/2009
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Provider Practice Location Address
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Address Line | 506 NORTH ST
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City | FARMINGTON
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State | MO
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Zip | 63640-3213
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Country | US
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Telephone | 573-756-3330
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Fax | 573-747-3023
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Provider Business Mailing Address
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Address Line | PO BOX 506
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City | FARMINGTON
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State | MO
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Zip | 63640-0506
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Country | US
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Telephone | 573-756-3330
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Fax | 573-747-3023
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Authorized Official
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Title or Position | COUNSELOR/OWNER
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Name | LYNN S JAMES
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Credential | LPC
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Telephone | 573-756-3330
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 001502
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License Number State | MO
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