Provider Demographics
NPI:1184703670
Name:CREATIVE LIFE SKILLS DEVELOPMENT
Entity type:Organization
Organization Name:CREATIVE LIFE SKILLS DEVELOPMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:HERRMANN
Authorized Official - Suffix:
Authorized Official - Credentials:MS OTR/L
Authorized Official - Phone:602-441-5975
Mailing Address - Street 1:15508 W BELL RD
Mailing Address - Street 2:SUITE 101-261
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-2432
Mailing Address - Country:US
Mailing Address - Phone:602-441-5975
Mailing Address - Fax:602-485-8859
Practice Address - Street 1:15508 W BELL RD
Practice Address - Street 2:SUITE 101-261
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-2432
Practice Address - Country:US
Practice Address - Phone:602-441-5975
Practice Address - Fax:602-485-8859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2251P0200X, 225XP0200X, 235Z00000X, 261QD1600X
AZ2762320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities