Provider Demographics
NPI:1518148279
Name:CREATIVE COMMUNITY SUPPORT, LLC
Entity Type:Organization
Organization Name:CREATIVE COMMUNITY SUPPORT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SALLAHDEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SPRUILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-413-0546
Mailing Address - Street 1:740 GREENVILLE BLVD SE STE 400
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-5135
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1206 EVANS ST STE 12
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-4102
Practice Address - Country:US
Practice Address - Phone:252-413-0546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-21
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health