Healthcare Provider Details

I. General information

NPI: 1184703670
Provider Name (Legal Business Name): CREATIVE LIFE SKILLS DEVELOPMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 09/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15508 W BELL RD SUITE 101-261
SURPRISE AZ
85374-2432
US

IV. Provider business mailing address

15508 W BELL RD SUITE 101-261
SURPRISE AZ
85374-2432
US

V. Phone/Fax

Practice location:
  • Phone: 602-441-5975
  • Fax: 602-485-8859
Mailing address:
  • Phone: 602-441-5975
  • Fax: 602-485-8859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number2762
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. LISA LYN HERRMANN
Title or Position: OWNER
Credential: M.S OTR/L
Phone: 602-441-5975