=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982908919
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CREATIVE CHALLENGE OUTREACH, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2011
-----------------------------------------------------
Last Update Date | 06/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3252 N 1ST ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53212-2061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-264-4522
-----------------------------------------------------
Fax | 414-264-2316
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3252 N 1ST ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53212-2061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-264-4522
-----------------------------------------------------
Fax | 414-264-2316
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR/PSYCHOTHERAPIST
-----------------------------------------------------
Name | MISS VIVIAN MARIE HOUSTON
-----------------------------------------------------
Credential | M.S., PHD
-----------------------------------------------------
Telephone | 414-736-9882
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251V00000X
-----------------------------------------------------
Taxonomy Name | Voluntary or Charitable Agency
-----------------------------------------------------
License Number | 590-226
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------