Provider Demographics
NPI:1619293024
Name:CREATIVE COUNSELING STUDIO, LLC
Entity Type:Organization
Organization Name:CREATIVE COUNSELING STUDIO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:703-507-6866
Mailing Address - Street 1:385 GARRISONVILLE ROAD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554
Mailing Address - Country:US
Mailing Address - Phone:703-507-6866
Mailing Address - Fax:
Practice Address - Street 1:385 GARRISONVILLE RD
Practice Address - Street 2:SUITE 112
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-1545
Practice Address - Country:US
Practice Address - Phone:703-507-6866
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-09
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701002736101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1659419067Medicaid