Provider Demographics
NPI:1710545413
Name:TW CREATIVE THERAPY, LLC
Entity Type:Organization
Organization Name:TW CREATIVE THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:C
Authorized Official - Last Name:WENIG
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:208-930-4003
Mailing Address - Street 1:1121 E MULLAN AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4054
Mailing Address - Country:US
Mailing Address - Phone:208-930-4003
Mailing Address - Fax:208-930-4043
Practice Address - Street 1:1121 E MULLAN AVE STE 210
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4054
Practice Address - Country:US
Practice Address - Phone:208-930-4003
Practice Address - Fax:208-930-4043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000588275003Medicaid