Provider Demographics
NPI:1346747169
Name:CREATIVE COUNSELING OF MILWAUKEE
Entity Type:Organization
Organization Name:CREATIVE COUNSELING OF MILWAUKEE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:MAC, LPC
Authorized Official - Phone:414-405-0670
Mailing Address - Street 1:2022 E EDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:53211-2935
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2266 E PROSPECT AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202
Practice Address - Country:US
Practice Address - Phone:414-405-0670
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5853-125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1619388451Medicaid