Healthcare Provider Details

I. General information

NPI: 1104591239
Provider Name (Legal Business Name): THE CO-CREATIVE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2021
Last Update Date: 08/11/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19712 MACARTHUR BLVD STE 101
IRVINE CA
92612-2407
US

IV. Provider business mailing address

19712 MACARTHUR BLVD STE 101
IRVINE CA
92612-2407
US

V. Phone/Fax

Practice location:
  • Phone: 949-385-1656
  • Fax:
Mailing address:
  • Phone: 949-385-1656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: PEGGY TSAI TRUONG
Title or Position: BEHAVIOR ANALYST
Credential: BCBA
Phone: 408-768-9800