Provider Demographics
NPI:1609196898
Name:THE CREATIVE THERAPY CENTER, LLC
Entity Type:Organization
Organization Name:THE CREATIVE THERAPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:763-274-0510
Mailing Address - Street 1:657 MAIN ST NW STE 214
Mailing Address - Street 2:
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-1584
Mailing Address - Country:US
Mailing Address - Phone:763-274-0510
Mailing Address - Fax:
Practice Address - Street 1:657 MAIN ST NW STE 214
Practice Address - Street 2:
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-1584
Practice Address - Country:US
Practice Address - Phone:763-274-0510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-10
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health