Provider Demographics
NPI:1760145379
Name:CREATIVE ISLAND THERAPY, LLC
Entity Type:Organization
Organization Name:CREATIVE ISLAND THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORINDA
Authorized Official - Middle Name:JEANNE
Authorized Official - Last Name:ROY
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:239-235-0522
Mailing Address - Street 1:1065 BORGHESE LN APT 1803
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34114-7918
Mailing Address - Country:US
Mailing Address - Phone:239-235-0522
Mailing Address - Fax:239-235-0512
Practice Address - Street 1:3384 WOODS EDGE CIR STE 104
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-1367
Practice Address - Country:US
Practice Address - Phone:239-235-0522
Practice Address - Fax:239-235-0512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty