Provider Demographics
NPI:1447978473
Name:CREATIVE CHANGE COUNSELING
Entity type:Organization
Organization Name:CREATIVE CHANGE COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BERTEE
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:JR
Authorized Official - Credentials:PSY D
Authorized Official - Phone:609-667-7353
Mailing Address - Street 1:668 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08048-5016
Mailing Address - Country:US
Mailing Address - Phone:609-668-4719
Mailing Address - Fax:609-667-7944
Practice Address - Street 1:2840 ROLLING FORK WAY
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:MD
Practice Address - Zip Code:21738-9746
Practice Address - Country:US
Practice Address - Phone:609-668-4719
Practice Address - Fax:609-667-7944
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CREATIVE CHANGE COUNSELING
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-08-16
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)