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General NPI Number Information
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NPI Number | 1750085056
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Entity Type | Organization
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Legal Business Name | CREATIVE ROOTS COUNSELING, LLC
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Dates
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Enumeration Date | 03/29/2023
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Last Update Date | 03/29/2023
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Provider Practice Location Address
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Address Line | 24 POLVADERA PL
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City | YOUNGSVILLE
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State | NM
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Zip | 87064-0199
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Country | US
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Telephone | 617-834-8204
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 817
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City | ABIQUIU
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State | NM
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Zip | 87510-0817
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SARAH GRENZEBACK
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Credential |
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Telephone | 617-834-8204
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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