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General NPI Number Information
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NPI Number | 1700313780
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Entity Type | Organization
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Legal Business Name | KINGDOM CREATIVE COUNSELING PLLC
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Dates
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Enumeration Date | 05/22/2017
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Last Update Date | 12/18/2024
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Provider Practice Location Address
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Address Line | 1050 REVOLUTION MILL DR STE 2
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City | GREENSBORO
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State | NC
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Zip | 27405-5053
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Country | US
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Telephone | 336-543-0159
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Fax | 336-663-2906
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Provider Business Mailing Address
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Address Line | PO BOX 14222
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City | GREENSBORO
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State | NC
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Zip | 27415-4222
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Country | US
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Telephone | 336-543-0159
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Fax | 336-663-2906
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Authorized Official
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Title or Position | OWNER
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Name | SAMARIA M COLBERT
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Credential | LCSW
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Telephone | 336-543-0159
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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 | C007049
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | C007049
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License Number State | NC
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