MEDICARE: CREATING FOUNDATIONS, 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	101Y00000X	Counselor	2005038691	MO

General Provider Information

NPI Number	:	1871894964
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CREATING FOUNDATIONS, LLC

Provider Business Mailing Address
First Line	:	7341 SE SYCAMORE DR
Second Line	:
City	:	HOLT
State	:	MO
Zip	:	64048-9386
Country	:	US
Telephone Number	:	816-699-2526
Fax Number	:

Provider Business Practice Location Address
First Line	:	8218 PENCE RD
Second Line	:
City	:	PLEASANT VALLEY
State	:	MO
Zip	:	64068-9586
Country	:	US
Telephone Number	:	816-699-2526
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. KRISTEEN K DOWNS
Credential	:	LPC
Telephone Number	:	816-699-2526

Provider Enumeration Date	:	11/05/2010
Last Update Date	:	11/05/2010

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