Provider Demographics
NPI:1972880300
Name:KREATIVE BEHAVIORAL HEALTH SERVICES, LLC
Entity Type:Organization
Organization Name:KREATIVE BEHAVIORAL HEALTH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KEITHA
Authorized Official - Middle Name:DONELLE
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:405-254-5040
Mailing Address - Street 1:5929 N MAY AVE
Mailing Address - Street 2:SUITE 218
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-3909
Mailing Address - Country:US
Mailing Address - Phone:405-254-5040
Mailing Address - Fax:405-254-5760
Practice Address - Street 1:5929 N MAY AVE
Practice Address - Street 2:SUITE 218
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-3909
Practice Address - Country:US
Practice Address - Phone:405-254-5040
Practice Address - Fax:405-254-5760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-14
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health