Provider Demographics
NPI:1790321263
Name:CREATIVE CHANGE FAMILY SERVICES LLC
Entity Type:Organization
Organization Name:CREATIVE CHANGE FAMILY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CEO
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:701-526-4885
Mailing Address - Street 1:PO BOX 459
Mailing Address - Street 2:
Mailing Address - City:SOMERS
Mailing Address - State:MT
Mailing Address - Zip Code:59932-0459
Mailing Address - Country:US
Mailing Address - Phone:701-526-4885
Mailing Address - Fax:
Practice Address - Street 1:65 COMMONS WAY
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-1908
Practice Address - Country:US
Practice Address - Phone:701-526-4885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-20
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty