Provider Demographics
NPI:1699051219
Name:CREATIVE LIFE COUNSELING
Entity type:Organization
Organization Name:CREATIVE LIFE COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:SUTHERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:502-741-6065
Mailing Address - Street 1:925 E 900 S
Mailing Address - Street 2:#42
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-1401
Mailing Address - Country:US
Mailing Address - Phone:801-657-0897
Mailing Address - Fax:801-363-6564
Practice Address - Street 1:925 E 900 S
Practice Address - Street 2:SUITE # 42
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-1401
Practice Address - Country:US
Practice Address - Phone:801-657-0897
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6985612-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty