Provider Demographics
NPI:1407125388
Name:CREEKSIDE SERVICES, LLC
Entity Type:Organization
Organization Name:CREEKSIDE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-786-4440
Mailing Address - Street 1:5800 MOUNTAIN CREEK RD NE
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5035
Mailing Address - Country:US
Mailing Address - Phone:404-228-6554
Mailing Address - Fax:404-963-0555
Practice Address - Street 1:5800 MOUNTAIN CREEK RD NE
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30328-5035
Practice Address - Country:US
Practice Address - Phone:404-228-6554
Practice Address - Fax:404-963-0555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-21
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALMSW0049981041C0700X
133N00000X, 171W00000X
GA164W00000X, 171M00000X, 175F00000X, 376K00000X
GA39171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No171W00000XOther Service ProvidersContractorGroup - Single Specialty
No175F00000XOther Service ProvidersNaturopathGroup - Single Specialty
No376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA006602OtherPCH
GA520306OtherJOINT COMMISSION HEALTHCARE ORGANIZATION