MEDICARE: CREATIVE MINDS BEHAVIORAL HEALTH, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588286793
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CREATIVE MINDS BEHAVIORAL HEALTH, LLC

Provider Business Mailing Address
First Line	:	110 W RANDOL MILL RD STE 200
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76011-4612
Country	:	US
Telephone Number	:	214-892-7151
Fax Number	:

Provider Business Practice Location Address
First Line	:	110 W RANDOL MILL RD STE 200
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76011-4612
Country	:	US
Telephone Number	:	214-892-7151
Fax Number	:	214-602-9919

Authorized Official
Title or Position	:	CREDENTIAL/BILLING
Name	:	TRALICA CLEWIS
Credential	:
Telephone Number	:	469-586-7643

Provider Enumeration Date	:	05/11/2020
Last Update Date	:	08/30/2020

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