MEDICARE: COUNSELING FOR CREATIVE CHANGE INC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1417726134
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNSELING FOR CREATIVE CHANGE INC

Provider Business Mailing Address
First Line	:	PO BOX 263
Second Line	:
City	:	WEIMAR
State	:	CA
Zip	:	95736-0263
Country	:	US
Telephone Number	:	916-595-8200
Fax Number	:

Provider Business Practice Location Address
First Line	:	22640 PINE LAKE DR
Second Line	:
City	:	COLFAX
State	:	CA
Zip	:	95713-9041
Country	:	US
Telephone Number	:	916-595-8200
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JOSH SINGER
Credential	:	MFT
Telephone Number	:	916-595-8200

Provider Enumeration Date	:	12/21/2023
Last Update Date	:	12/21/2023

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