1992724934 NPI number — CRISARA CREATIVE THERAPY, LLC

Table of content: (NPI 1992724934)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992724934 NPI number — CRISARA CREATIVE THERAPY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRISARA CREATIVE THERAPY, 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:
1992724934
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 581748
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELK GROVE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95758-0030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-422-8862
Provider Business Mailing Address Fax Number:
916-422-2050

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7000 FRANKLIN BOULEVARD
Provider Second Line Business Practice Location Address:
SUITE 350
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95823-1839
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-422-8862
Provider Business Practice Location Address Fax Number:
916-422-2050
Provider Enumeration Date:
07/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
AVA
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
CEO/DIRECTOR OF COUNSELING
Authorized Official Telephone Number:
916-422-8862

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: 9555 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: V797P-7015A . This is a "FEDERAL GSA/FSS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 31474 . This is a "DEPT OF TRANSPORTATION" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ67877Z . This is a "BLUE SHIELD/BLUE CROSS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 6DN00022 . This is a "CPUC" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com