Provider Demographics
NPI:1366111783
Name:CREATIVE MIND PSYCHOTHERAPY PLLC
Entity type:Organization
Organization Name:CREATIVE MIND PSYCHOTHERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:912-610-2107
Mailing Address - Street 1:5035 LANGDALE WAY
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-7673
Mailing Address - Country:US
Mailing Address - Phone:912-610-2107
Mailing Address - Fax:
Practice Address - Street 1:5035 LANGDALE WAY
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-7673
Practice Address - Country:US
Practice Address - Phone:912-610-2107
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health