Provider Demographics
NPI:1255085056
Name:CREATIVE SPACE CHILD THERAPY, LLC.
Entity type:Organization
Organization Name:CREATIVE SPACE CHILD THERAPY, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LATRICE
Authorized Official - Middle Name:KIANE
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:410-929-7427
Mailing Address - Street 1:5304 CEDAR DR
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21613-4404
Mailing Address - Country:US
Mailing Address - Phone:410-929-7427
Mailing Address - Fax:
Practice Address - Street 1:5304 CEDAR DR
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-4404
Practice Address - Country:US
Practice Address - Phone:410-929-7427
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty