Healthcare Provider Details

I. General information

NPI: 1023738739
Provider Name (Legal Business Name): CR8TIVE MINDZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2022
Last Update Date: 09/01/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1777 N BELLFLOWER BLVD STE 105
LONG BEACH CA
90815-4019
US

IV. Provider business mailing address

556 W 3RD ST
SAN PEDRO CA
90731-2506
US

V. Phone/Fax

Practice location:
  • Phone: 323-402-1803
  • Fax:
Mailing address:
  • Phone: 323-402-1803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KANDICE GRAY
Title or Position: CEO/CO-FOUNDER, LCSW
Credential:
Phone: 310-654-7485