CREATIVE COMMUNITY SERVICE, INC.

Provider Demographics

• NPI: 1891820130
• Name: CREATIVE COMMUNITY SERVICE, INC.
• Entity Type: Organization
• Organization Name: CREATIVE COMMUNITY SERVICE, INC.
• Authorized Official - Title/Position: CHIEF OPERATING OFFICER
• Authorized Official - Prefix: MS
• Authorized Official - First Name: CATHY
• Authorized Official - Last Name: PALLON
• Authorized Official - Phone: 770-469-6226
• Mailing Address - Street 1: 4487 PARK DR
• Mailing Address - Street 2: SUITE A
• Mailing Address - City: NORCROSS
• Mailing Address - State: GA
• Mailing Address - Zip Code: 30093-2964
• Mailing Address - Country: US
• Mailing Address - Phone: 770-469-6226
• Mailing Address - Fax: 678-894-4081
• Practice Address - Street 1: 4487 PARK DR
• Practice Address - Street 2: SUITE A
• Practice Address - City: NORCROSS
• Practice Address - State: GA
• Practice Address - Zip Code: 30093-2964
• Practice Address - Country: US
• Practice Address - Phone: 770-469-6226
• Practice Address - Fax: 678-894-4081
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2007-02-23
• Last Update Date: 2008-05-21

Provider Licenses

State	License ID	Taxonomies
GA	060-R-0018	251C00000X, 251S00000X
GA	CP-FC0040079	251S00000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	251S00000X	Agencies	Community/Behavioral Health
No	251C00000X	Agencies	Day Training, Developmentally Disabled Services

Provider Identifiers

State	Identifier ID	ID Type	Issuer
GA	000565375AA	Medicaid
GA	000565375AC	Medicaid
GA	000565375F	Medicaid
GA	000565375G	Medicaid
GA	000565375J	Medicaid
GA	000565375Y	Medicaid
GA	000565375AD	Medicaid
GA	000565375AF	Medicaid
GA	000565375AL	Medicaid
GA	000565375AN	Medicaid
GA	000565375N	Medicaid
GA	000565375P	Medicaid
GA	000565375U	Medicaid
GA	000565375AB	Medicaid
GA	000565375AK	Medicaid
GA	000565375M	Medicaid
GA	000565375V	Medicaid
GA	000565375W	Medicaid
GA	000565375Z	Medicaid
GA	000565375L	Medicaid
GA	000565375Q	Medicaid
GA	000565375AM	Medicaid
GA	000565375I	Medicaid
GA	300025237-C	Medicaid
GA	000565375AE	Medicaid
GA	000565375AI	Medicaid
GA	000565375AJ	Medicaid
GA	000565375R	Medicaid
GA	000565375S	Medicaid
GA	000565375X	Medicaid
GA	000565375K	Medicaid
GA	000565375O	Medicaid
GA	000565375T	Medicaid
GA	000565375AG	Medicaid
GA	000565375AH	Medicaid
GA	000565375B	Medicaid
GA	000565375H	Medicaid