Provider Demographics
NPI:1447564547
Name:CREATING CHANGE
Entity Type:Organization
Organization Name:CREATING CHANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-671-1315
Mailing Address - Street 1:PO BOX 1503
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84091-1503
Mailing Address - Country:US
Mailing Address - Phone:801-671-1315
Mailing Address - Fax:
Practice Address - Street 1:3098 HIGHLAND DR STE 369
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-6007
Practice Address - Country:US
Practice Address - Phone:801-671-1315
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-30
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT68850903501251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health