Provider Demographics
NPI:1508234295
Name:CREATIVE THERAPY PLLC
Entity Type:Organization
Organization Name:CREATIVE THERAPY PLLC
Other - Org Name:CREATIVE THERAPY ADDICTION PROGRAM
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/ MENTAL HEALTH COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:EBERLE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:701-490-3281
Mailing Address - Street 1:150 2ND ST SW
Mailing Address - Street 2:#1
Mailing Address - City:VALLEY CITY
Mailing Address - State:ND
Mailing Address - Zip Code:58072-3302
Mailing Address - Country:US
Mailing Address - Phone:701-490-3281
Mailing Address - Fax:701-490-3283
Practice Address - Street 1:150 2ND ST SW
Practice Address - Street 2:#1
Practice Address - City:VALLEY CITY
Practice Address - State:ND
Practice Address - Zip Code:58072-3302
Practice Address - Country:US
Practice Address - Phone:701-490-3281
Practice Address - Fax:701-490-3283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-11
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND56667Medicaid