Provider Demographics
NPI:1982862405
Name:CREATIVE CHANGE THERAPY CENTER LLP
Entity Type:Organization
Organization Name:CREATIVE CHANGE THERAPY CENTER LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENT
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:BEDUHN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:301-754-0122
Mailing Address - Street 1:10702 LOMBARDY RD
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20901-1631
Mailing Address - Country:US
Mailing Address - Phone:301-754-0122
Mailing Address - Fax:
Practice Address - Street 1:10702 LOMBARDY RD
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20901-1631
Practice Address - Country:US
Practice Address - Phone:301-754-0122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD4026103TC0700X
MD056591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty