Provider Demographics
NPI:1568116002
Name:CREATIVE COUNSELING AND CONSULTATION, PLLC
Entity Type:Organization
Organization Name:CREATIVE COUNSELING AND CONSULTATION, PLLC
Other - Org Name:CREATIVE COUNSELING & CONSULTATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:LONGORIA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:270-872-3540
Mailing Address - Street 1:1518 YORKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-9191
Mailing Address - Country:US
Mailing Address - Phone:270-872-3540
Mailing Address - Fax:
Practice Address - Street 1:110 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2423
Practice Address - Country:US
Practice Address - Phone:270-594-1199
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-03
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100819490Medicaid