Provider Demographics
NPI:1508294059
Name:CREATIVE CARE 2
Entity Type:Organization
Organization Name:CREATIVE CARE 2
Other - Org Name:ADULT CREATIVE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-713-1018
Mailing Address - Street 1:6405 MIDDLEBELT RD
Mailing Address - Street 2:
Mailing Address - City:ROMULUS
Mailing Address - State:MI
Mailing Address - Zip Code:48174-2036
Mailing Address - Country:US
Mailing Address - Phone:734-895-6505
Mailing Address - Fax:
Practice Address - Street 1:6405 MIDDLEBELT RD
Practice Address - Street 2:
Practice Address - City:ROMULUS
Practice Address - State:MI
Practice Address - Zip Code:48174-2036
Practice Address - Country:US
Practice Address - Phone:734-895-6505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-18
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty