MEDICARE: CREATIVE ROOTS COUNSELING, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	180008745	IL

General Provider Information

NPI Number	:	1316460728
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CREATIVE ROOTS COUNSELING, LLC

Provider Business Mailing Address
First Line	:	4305 N LINCOLN AVE STE K
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-1807
Country	:	US
Telephone Number	:	773-466-4527
Fax Number	:

Provider Business Practice Location Address
First Line	:	4305 N LINCOLN AVE STE K
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-1807
Country	:	US
Telephone Number	:	773-466-4527
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOTHERAPIST
Name	:	KRISTINA VOGT
Credential	:	LCPC, ATR
Telephone Number	:	773-466-4527

Provider Enumeration Date	:	07/18/2017
Last Update Date	:	07/21/2022

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