MEDICARE: CREATIVE LIVING COUNSELING CENTER

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1942499017
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CREATIVE LIVING COUNSELING CENTER

Provider Business Mailing Address
First Line	:	172 RIVINGTON ST
Second Line	:	APT. # 9
City	:	NEW YORK
State	:	NY
Zip	:	10002-2513
Country	:	US
Telephone Number	:	212-533-0755
Fax Number	:

Provider Business Practice Location Address
First Line	:	37 E ALLENDALE AVE
Second Line	:
City	:	ALLENDALE
State	:	NJ
Zip	:	07401-2095
Country	:	US
Telephone Number	:	201-327-2424
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DR. GRETCHEN WHITE JANSSEN
Credential	:	DMIN
Telephone Number	:	201-327-2424

Provider Enumeration Date	:	10/15/2007
Last Update Date	:	10/15/2007

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