Provider Demographics
NPI:1386068617
Name:CREATIVE CHANGE COUNSELING CENTER
Entity type:Organization
Organization Name:CREATIVE CHANGE COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN ASST
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-255-5526
Mailing Address - Street 1:PO BOX 4158
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-4158
Mailing Address - Country:US
Mailing Address - Phone:425-255-5526
Mailing Address - Fax:425-255-5523
Practice Address - Street 1:200 S TOBIN ST STE A
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-5338
Practice Address - Country:US
Practice Address - Phone:425-255-5526
Practice Address - Fax:425-255-5523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACL60152004101Y00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty