Provider Demographics
NPI:1578813119
Name:CREEK, DAVID J (LMFT)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:J
Last Name:CREEK
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6653 WEAVER RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-8025
Mailing Address - Country:US
Mailing Address - Phone:815-200-9636
Mailing Address - Fax:
Practice Address - Street 1:6653 WEAVER RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-8025
Practice Address - Country:US
Practice Address - Phone:815-200-9636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-11
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166001308106H00000X
MN3239106H00000X
IL166.001308106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN360450100MMedicaid