Basic Information
| Provider Information | |||||||||
| NPI: | 1043842750 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARY S STRONG CREATIVE COMMUNITY COUNSELING | ||||||||
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| Mailing Information | |||||||||
| Address1: | 731 ACKLEN ST | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711043901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182882686 | ||||||||
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| Practice Location | |||||||||
| Address1: | 719 S AUSTIN ST | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791066714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183506767 | ||||||||
| FaxNumber: | 3183506767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2020 | ||||||||
| LastUpdateDate: | 12/10/2021 | ||||||||
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| AuthorizedOfficialLastName: | STRONG | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | SOSONYA | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3182882686 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CREATIVE COMMUNITY COUNSELING LLC | ||||||||
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| AuthorizedOfficialCredential: | RSW, LPC, RPT, CAS | ||||||||
| NPICertificationDate: | 12/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1043842750 | 05 | LA | MEDICAID | 2832407 | 05 | TX | MEDICAID | 28327407 | 05 | TX | MEDICAID |