Provider Demographics
NPI:1003109802
Name:CREATIVE COLLABORATION
Entity Type:Organization
Organization Name:CREATIVE COLLABORATION
Other - Org Name:CC YOUTH EMPOWERMENT SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BONITO
Authorized Official - Middle Name:
Authorized Official - Last Name:SAHAGUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-610-4153
Mailing Address - Street 1:8070 W RUSSELL RD
Mailing Address - Street 2:APT 1065
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-1549
Mailing Address - Country:US
Mailing Address - Phone:702-610-4153
Mailing Address - Fax:
Practice Address - Street 1:8070 W RUSSELL RD
Practice Address - Street 2:APT 1065
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-1549
Practice Address - Country:US
Practice Address - Phone:702-610-4153
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty