MEDICARE: CREATIVE COMMUNITY COUNSELING, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	251B00000X	Case Management Agency
2	251S00000X	Community/Behavioral Health Agency
3	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
4	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1043694219
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CREATIVE COMMUNITY COUNSELING, INC.

Provider Business Mailing Address
First Line	:	202 LAKE MIRIAM DR
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33813-2180
Country	:	US
Telephone Number	:	863-226-5081
Fax Number	:

Provider Business Practice Location Address
First Line	:	202 LAKE MIRIAM DR
Second Line	:	W6
City	:	LAKELAND
State	:	FL
Zip	:	33813-2180
Country	:	US
Telephone Number	:	863-226-5081
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	CATHY GHENT
Credential	:	LMHC
Telephone Number	:	863-226-5081

Provider Enumeration Date	:	07/16/2015
Last Update Date	:	10/21/2024

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