Provider Demographics
NPI:1437480639
Name:CREATIVE FOUNDATION, LLC
Entity Type:Organization
Organization Name:CREATIVE FOUNDATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
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 1:1775 GRAHAM AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536-5948
Mailing Address - Country:US
Mailing Address - Phone:252-529-9054
Mailing Address - Fax:252-572-4981
Practice Address - Street 1:1775 GRAHAM AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-5948
Practice Address - Country:US
Practice Address - Phone:252-529-9054
Practice Address - Fax:252-572-4981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-27
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No251B00000XAgenciesCase ManagementGroup - Single Specialty