Provider Demographics
NPI:1063724771
Name:CREATIVE ALTERNATIVES FOR PSYCHOLOGICAL GROWTH LLC
Entity type:Organization
Organization Name:CREATIVE ALTERNATIVES FOR PSYCHOLOGICAL GROWTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:VINEHOUT
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:815-245-6669
Mailing Address - Street 1:PO BOX 1861
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-1861
Mailing Address - Country:US
Mailing Address - Phone:815-245-6669
Mailing Address - Fax:
Practice Address - Street 1:645 MCHENRY AVE
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-2922
Practice Address - Country:US
Practice Address - Phone:815-245-6669
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-10
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071006683251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2201382OtherCOMPSYCH
IL600016110OtherMAGELLAN
IL11894012OtherCAQH
IL35641736OtherBCBS