Provider Demographics
NPI:1417308941
Name:CREATIVE INDEPENDENT ALLIANCE
Entity Type:Organization
Organization Name:CREATIVE INDEPENDENT ALLIANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PENDLETON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-275-2393
Mailing Address - Street 1:1 INTERNATIONAL PLZ
Mailing Address - Street 2:SUITE 550
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19113-1510
Mailing Address - Country:US
Mailing Address - Phone:267-275-2393
Mailing Address - Fax:
Practice Address - Street 1:1 INTERNATIONAL PLZ
Practice Address - Street 2:SUITE 550
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19113-1510
Practice Address - Country:US
Practice Address - Phone:267-275-2393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-27
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 252Y00000X
PA6417465251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No252Y00000XAgenciesEarly Intervention Provider Agency