Provider Demographics
NPI:1780846048
Name:CREATIVE CHANGE COUNSELING CENTER
Entity Type:Organization
Organization Name:CREATIVE CHANGE COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C. E. O.
Authorized Official - Prefix:MR
Authorized Official - First Name:FOREST
Authorized Official - Middle Name:E
Authorized Official - Last Name:WOODLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MHP, CDC
Authorized Official - Phone:409-838-3200
Mailing Address - Street 1:3350 MCFADDIN ST
Mailing Address - Street 2:SUITE 7
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-5033
Mailing Address - Country:US
Mailing Address - Phone:409-838-3200
Mailing Address - Fax:409-838-3201
Practice Address - Street 1:3350 MCFADDIN ST
Practice Address - Street 2:SUITE 7
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-5033
Practice Address - Country:US
Practice Address - Phone:409-838-3200
Practice Address - Fax:409-838-3201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-27
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty