Provider Demographics
NPI:1881822872
Name:CREATIVE COUNSELING & WELLNESS CENTER CORP
Entity Type:Organization
Organization Name:CREATIVE COUNSELING & WELLNESS CENTER CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SONYA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:OGLESBY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:336-831-4051
Mailing Address - Street 1:163 STRATFORD CT
Mailing Address - Street 2:SUITE 170
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1836
Mailing Address - Country:US
Mailing Address - Phone:336-831-4051
Mailing Address - Fax:336-436-9123
Practice Address - Street 1:163 STRATFORD CT
Practice Address - Street 2:SUITE 170
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1836
Practice Address - Country:US
Practice Address - Phone:336-831-4051
Practice Address - Fax:336-436-9123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-29
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3028A101YA0400X
NC8040101YM0800X, 101YP2500X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6115116Medicaid