MEDICARE: KREATIVE COUNSELING GROUP

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		VA

General Provider Information

NPI Number	:	1992061170
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KREATIVE COUNSELING GROUP

Provider Business Mailing Address
First Line	:	4410 EAST CLAIBORNE SQUARE
Second Line	:	SUITE 334/OFFICE 321
City	:	HAMPTON
State	:	VA
Zip	:	23666
Country	:	US
Telephone Number	:	804-933-2082
Fax Number	:

Provider Business Practice Location Address
First Line	:	4410 CLAIBORNE SQ E
Second Line	:	SUITE 334/OFFICE 321
City	:	HAMPTON
State	:	VA
Zip	:	23666-2071
Country	:	US
Telephone Number	:	804-933-2082
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. SYDNEY A VANLOW JR.
Credential	:
Telephone Number	:	804-933-2082

Provider Enumeration Date	:	04/02/2012
Last Update Date	:	04/02/2012

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