Provider Demographics
NPI:1346488491
Name:CREATIVE CHANGE, INC.
Entity Type:Organization
Organization Name:CREATIVE CHANGE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TED
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:PEARSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LMHC
Authorized Official - Phone:352-597-0969
Mailing Address - Street 1:5331 COMMERCIAL WAY STE 212
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34606-1426
Mailing Address - Country:US
Mailing Address - Phone:352-597-0969
Mailing Address - Fax:352-597-6853
Practice Address - Street 1:5331 COMMERCIAL WAY STE 212
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34606-1426
Practice Address - Country:US
Practice Address - Phone:352-597-0969
Practice Address - Fax:352-597-6853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-28
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH2746101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11915921OtherCAQH