Provider Demographics
NPI:1386876738
Name:CREATIVE COUNSELING CENTER, LLC
Entity type:Organization
Organization Name:CREATIVE COUNSELING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:J
Authorized Official - Last Name:CHOVITZ
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LADC
Authorized Official - Phone:203-215-6125
Mailing Address - Street 1:408 HIGHLAND AVE STE A
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-2525
Mailing Address - Country:US
Mailing Address - Phone:203-215-6125
Mailing Address - Fax:203-288-7485
Practice Address - Street 1:408 HIGHLAND AVE STE A
Practice Address - Street 2:
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410-2525
Practice Address - Country:US
Practice Address - Phone:203-215-6125
Practice Address - Fax:203-288-7485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-19
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000063101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004240008Medicaid