MEDICARE: CREATING SUCCESS THERAPY PLLC

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1801551338
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CREATING SUCCESS THERAPY PLLC

Provider Business Mailing Address
First Line	:	15 OREGON AVE STE 111
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98409-7461
Country	:	US
Telephone Number	:	253-861-5165
Fax Number	:

Provider Business Practice Location Address
First Line	:	15 OREGON AVE STE 111
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98409-7461
Country	:	US
Telephone Number	:	253-861-5165
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST/OWNER
Name	:	KIMBERLY A REARDON
Credential	:	LMHC
Telephone Number	:	253-861-5165

Provider Enumeration Date	:	10/31/2021
Last Update Date	:	06/04/2022

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