Provider Demographics
NPI:1396216321
Name:CREATIVE PLAY THERAPY LLC
Entity Type:Organization
Organization Name:CREATIVE PLAY THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:E
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:479-226-6364
Mailing Address - Street 1:4705 JUNIPER CT
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-2232
Mailing Address - Country:US
Mailing Address - Phone:479-226-6364
Mailing Address - Fax:
Practice Address - Street 1:2713 S 74TH ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5170
Practice Address - Country:US
Practice Address - Phone:479-831-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1700211018Medicaid