Provider Demographics
NPI:1417364977
Name:CREATIVE THERAPY
Entity Type:Organization
Organization Name:CREATIVE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:EBERLE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, NCC
Authorized Official - Phone:701-367-8293
Mailing Address - Street 1:323 CENTRAL AVE N
Mailing Address - Street 2:SUITE 203
Mailing Address - City:VALLEY CITY
Mailing Address - State:ND
Mailing Address - Zip Code:58072-2915
Mailing Address - Country:US
Mailing Address - Phone:701-367-8293
Mailing Address - Fax:701-490-3283
Practice Address - Street 1:323 CENTRAL AVE N
Practice Address - Street 2:SUITE 203
Practice Address - City:VALLEY CITY
Practice Address - State:ND
Practice Address - Zip Code:58072-2915
Practice Address - Country:US
Practice Address - Phone:701-367-8293
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-16
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND694-8-1-11251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1455895Medicaid
ND1462435Medicaid