Provider Demographics
NPI:1811200173
Name:CREATIVE CHANGE COUNSELING CENTER
Entity Type:Organization
Organization Name:CREATIVE CHANGE COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:FOREST
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:WOODLEY
Authorized Official - Suffix:
Authorized Official - Credentials:AFFILIATED COUNSELOR
Authorized Official - Phone:425-255-5526
Mailing Address - Street 1:PO BOX 4158
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-4158
Mailing Address - Country:US
Mailing Address - Phone:425-255-5526
Mailing Address - Fax:425-255-5523
Practice Address - Street 1:220 SW BLVD.
Practice Address - Street 2:SUITE B102
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-4158
Practice Address - Country:US
Practice Address - Phone:425-255-5526
Practice Address - Fax:425-255-5523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-15
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA221251B00000X
WA17149100251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management