Provider Demographics
NPI:1144607961
Name:CREATIVE ROOTS THERAPY LLC
Entity Type:Organization
Organization Name:CREATIVE ROOTS THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:SPIER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:541-808-4719
Mailing Address - Street 1:PO BOX 576
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420
Mailing Address - Country:US
Mailing Address - Phone:541-808-4719
Mailing Address - Fax:
Practice Address - Street 1:375 PARK AVE
Practice Address - Street 2:SUITE B
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420
Practice Address - Country:US
Practice Address - Phone:541-808-4719
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-30
Last Update Date:2015-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3450101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500673890Medicaid