Provider Demographics
NPI:1437306735
Name:CREATIVE FOUNDATIONS
Entity Type:Organization
Organization Name:CREATIVE FOUNDATIONS
Other - Org Name:CREATIVE FOUNDATIONS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KENYETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:MASSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-529-9054
Mailing Address - Street 1:8229 WILLOWGLEN DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-3346
Mailing Address - Country:US
Mailing Address - Phone:252-529-9054
Mailing Address - Fax:
Practice Address - Street 1:1775 GRAHAM AVE STE 103
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-2996
Practice Address - Country:US
Practice Address - Phone:252-529-9054
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-19
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
NC251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8302451GMedicaid
NC3418608Medicaid
NC6006505Medicaid
NC8302451BMedicaid