Provider Demographics
NPI:1902370422
Name:CREATIVE COUNSELING FOR HEALTHY LIVING, LLC
Entity Type:Organization
Organization Name:CREATIVE COUNSELING FOR HEALTHY LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:WELVAERT-KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:MS ED, LCPC
Authorized Official - Phone:309-429-8959
Mailing Address - Street 1:5030 38TH AVE STE 10&11
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6717
Mailing Address - Country:US
Mailing Address - Phone:309-429-8959
Mailing Address - Fax:
Practice Address - Street 1:5030 38TH AVE STE 10&11
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6717
Practice Address - Country:US
Practice Address - Phone:309-429-8959
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)