Provider Demographics
NPI:1598983710
Name:CREATIVE LIFE SKILLS DEVELOPMENT, INC
Entity Type:Organization
Organization Name:CREATIVE LIFE SKILLS DEVELOPMENT, INC
Other - Org Name:CREATIVE LIFE SKILLS DEVELOPMENT, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:HERRMANN
Authorized Official - Suffix:
Authorized Official - Credentials:MS OTR
Authorized Official - Phone:602-441-5975
Mailing Address - Street 1:PO BOX 71726
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-1013
Mailing Address - Country:US
Mailing Address - Phone:602-441-5975
Mailing Address - Fax:602-485-8859
Practice Address - Street 1:1941 E WESCOTT DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85024-2434
Practice Address - Country:US
Practice Address - Phone:602-441-5975
Practice Address - Fax:602-485-8859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2762320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities