1679719652 NPI number — CREATIVE PSYCHOLOGICAL SOLUTIONS LLC

Table of content: (NPI 1679719652)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679719652 NPI number — CREATIVE PSYCHOLOGICAL SOLUTIONS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CREATIVE PSYCHOLOGICAL SOLUTIONS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679719652
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 W MEADOW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORTLAND
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60112-4226
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-355-4292
Provider Business Mailing Address Fax Number:
815-356-7139

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 E CONGRESS PKWY
Provider Second Line Business Practice Location Address:
SUITE L
Provider Business Practice Location Address City Name:
CRYSTAL LAKE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60014-6284
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-355-4292
Provider Business Practice Location Address Fax Number:
815-356-7139
Provider Enumeration Date:
12/23/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DEAN
Authorized Official First Name:
CATHERINE
Authorized Official Middle Name:
Authorized Official Title or Position:
SOLE MEMBER
Authorized Official Telephone Number:
815-355-4292

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  071-006447 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103T00000X , with the licence number: 3-1970 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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