Provider Demographics
NPI:1154837946
Name:CREATIVE CENTER FOR WELLNESS, INCORPORATED
Entity Type:Organization
Organization Name:CREATIVE CENTER FOR WELLNESS, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MANDY
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:770-599-7508
Mailing Address - Street 1:204 W SPRING ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-1914
Mailing Address - Country:US
Mailing Address - Phone:707-599-7508
Mailing Address - Fax:
Practice Address - Street 1:204 W SPRING ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-1914
Practice Address - Country:US
Practice Address - Phone:707-599-7508
Practice Address - Fax:866-734-7631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-16
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
GACSW0043541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty