Provider Demographics
NPI:1053794065
Name:CREATIVE CHANGE COUNSELING
Entity type:Organization
Organization Name:CREATIVE CHANGE COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM OPERATIONS EXECUTIVE DIRECT
Authorized Official - Prefix:
Authorized Official - First Name:BERTEE
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-668-4719
Mailing Address - Street 1:774 EAYRESTOWN RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LUMBERTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08048-3100
Mailing Address - Country:US
Mailing Address - Phone:609-668-4719
Mailing Address - Fax:
Practice Address - Street 1:423 7TH AVE SW
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-3237
Practice Address - Country:US
Practice Address - Phone:609-668-4719
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-08
Last Update Date:2022-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ103TC1900X, 261QM0801X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0506460Medicaid
NC1053794065Medicaid