Provider Demographics
NPI:1538500699
Name:CREATIVE LIFE BEHAVIORAL HEALTH SERVICE
Entity Type:Organization
Organization Name:CREATIVE LIFE BEHAVIORAL HEALTH SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIORAL HEALTH SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:CHARLETTA
Authorized Official - Middle Name:I
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-249-3668
Mailing Address - Street 1:5175 CAMINO EL NORTE
Mailing Address - Street 2:SUITE #100
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031
Mailing Address - Country:US
Mailing Address - Phone:702-648-3913
Mailing Address - Fax:
Practice Address - Street 1:5175 CAMINO EL NORTE
Practice Address - Street 2:SUITE #100
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031
Practice Address - Country:US
Practice Address - Phone:702-648-3913
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVX251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health