Provider Demographics
NPI:1275787400
Name:CREATIVE THERAPEUTICS, LLC
Entity Type:Organization
Organization Name:CREATIVE THERAPEUTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENT/MANAGER AND MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:HENNESSEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:860-429-2500
Mailing Address - Street 1:140 CRANE HILL RD
Mailing Address - Street 2:
Mailing Address - City:STORRS MANSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06268-2800
Mailing Address - Country:US
Mailing Address - Phone:860-377-2996
Mailing Address - Fax:
Practice Address - Street 1:1066 STORRS RD
Practice Address - Street 2:SUITE C
Practice Address - City:STORRS MANSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06268-2648
Practice Address - Country:US
Practice Address - Phone:860-429-2500
Practice Address - Fax:860-429-2501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-14
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000568106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000568OtherSTATE OF CT DEPARTMENT OF PUBLIC HEALTH