Provider Demographics
NPI:1760801427
Name:CREATIVE APPROACH PROGRAM
Entity Type:Organization
Organization Name:CREATIVE APPROACH PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:LAVERNE
Authorized Official - Last Name:BELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-232-8207
Mailing Address - Street 1:11489 STEPONIA BAY ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89141-3219
Mailing Address - Country:US
Mailing Address - Phone:702-232-8207
Mailing Address - Fax:
Practice Address - Street 1:11489 STEPONIA BAY ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89141-3219
Practice Address - Country:US
Practice Address - Phone:702-232-8207
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-10
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVE0094762014-2251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1992127302Medicaid