=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760626527
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CREATIVE COUNSELING SOLUTIONS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2009
-----------------------------------------------------
Last Update Date | 06/16/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 345 UNION ST
-----------------------------------------------------
City | NEW BEDFORD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02740-3679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-717-0212
-----------------------------------------------------
Fax | 508-717-0212
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 345 UNION ST
-----------------------------------------------------
City | NEW BEDFORD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02740-3679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-717-0212
-----------------------------------------------------
Fax | 508-717-0212
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. ROBERT EDWARD KONKEL
-----------------------------------------------------
Credential | LICSW
-----------------------------------------------------
Telephone | 508-717-0212
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 1022691
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------