Provider Demographics
NPI:1386178838
Name:CREATIVE COUNSELING GROUP, LLC
Entity Type:Organization
Organization Name:CREATIVE COUNSELING GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:CONNER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, RMHCI
Authorized Official - Phone:407-810-8319
Mailing Address - Street 1:1928 PROCTOR AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-4200
Mailing Address - Country:US
Mailing Address - Phone:407-810-8319
Mailing Address - Fax:
Practice Address - Street 1:1928 PROCTOR AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-4200
Practice Address - Country:US
Practice Address - Phone:407-810-8319
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH14125251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health