Provider Demographics
NPI:1376976829
Name:CREATIVE COUNSELING CENTERS, LLC
Entity type:Organization
Organization Name:CREATIVE COUNSELING CENTERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GWEN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MUNDORF
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:321-615-0990
Mailing Address - Street 1:5972 GOLETA CIR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-8035
Mailing Address - Country:US
Mailing Address - Phone:321-615-0990
Mailing Address - Fax:888-341-8272
Practice Address - Street 1:3270 SUNTREE BLVD
Practice Address - Street 2:SUITE 2233
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-7530
Practice Address - Country:US
Practice Address - Phone:321-615-0990
Practice Address - Fax:888-341-8272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-19
Last Update Date:2014-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW10736251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health