1720364045 NPI number — KREATIVE CONNEXIONS THERAPY SERVICES, LLC

Table of content: (NPI 1720364045)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720364045 NPI number — KREATIVE CONNEXIONS THERAPY SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KREATIVE CONNEXIONS THERAPY SERVICES, 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:
1720364045
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 340663
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53234-0663
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-313-5213
Provider Business Mailing Address Fax Number:
414-755-0633

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3111 W NATIONAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53215-1127
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-313-5213
Provider Business Practice Location Address Fax Number:
414-755-0633
Provider Enumeration Date:
11/01/2011

Additional Information

Authorized Official

Authorized Official Last Name:
VANG
Authorized Official First Name:
LYSSA
Authorized Official Middle Name:
K
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
414-313-5213

Provider Taxonomy Codes

  • Taxonomy code: 261QR0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com