Provider Demographics
NPI:1760515498
Name:CREATIVE CHANGE, LLC
Entity Type:Organization
Organization Name:CREATIVE CHANGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGED CARE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BENDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-962-7788
Mailing Address - Street 1:8772 BIG BEND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-3730
Mailing Address - Country:US
Mailing Address - Phone:314-962-7788
Mailing Address - Fax:314-962-4158
Practice Address - Street 1:8772 BIG BEND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-3730
Practice Address - Country:US
Practice Address - Phone:314-962-7788
Practice Address - Fax:314-962-4158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty