MEDICARE: NEW CREATION COUNSELING AND THERAPEUTIC BODYWORK 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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1558125468
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW CREATION COUNSELING AND THERAPEUTIC BODYWORK INC

Provider Business Mailing Address
First Line	:	5878 MIZPAH CT
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33810-1841
Country	:	US
Telephone Number	:	630-207-5537
Fax Number	:	888-873-1159

Provider Business Practice Location Address
First Line	:	5878 MIZPAH CT
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33810-1841
Country	:	US
Telephone Number	:	630-207-5537
Fax Number	:	888-873-1159

Authorized Official
Title or Position	:	PRESIDENT
Name	:	PAMELA DIANE TRICE
Credential	:	PSYD
Telephone Number	:	630-207-5537

Provider Enumeration Date	:	02/12/2024
Last Update Date	:	02/13/2024

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