Provider Demographics
NPI:1457820086
Name:CREAMER, HOLLY MARIE (BCBA)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:MARIE
Last Name:CREAMER
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:971 E. WICHITA AVE.
Mailing Address - Street 2:
Mailing Address - City:RUSSELL
Mailing Address - State:KS
Mailing Address - Zip Code:67665
Mailing Address - Country:US
Mailing Address - Phone:785-657-7464
Mailing Address - Fax:785-445-4042
Practice Address - Street 1:971 E. WICHITA AVE.
Practice Address - Street 2:
Practice Address - City:RUSSELL
Practice Address - State:KS
Practice Address - Zip Code:67665
Practice Address - Country:US
Practice Address - Phone:785-657-7464
Practice Address - Fax:785-445-4042
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-13
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
KS222Q00000X, 385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201234000AMedicaid