Healthcare Provider Details

I. General information

NPI: 1770985004
Provider Name (Legal Business Name): M2 CREATIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2014
Last Update Date: 09/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6715 MELROSE AVE
LOS ANGELES CA
90038-3411
US

IV. Provider business mailing address

22287 MULHOLLAND HWY
CALABASAS CA
91302-5157
US

V. Phone/Fax

Practice location:
  • Phone: 888-870-2201
  • Fax:
Mailing address:
  • Phone: 818-635-9380
  • Fax: 818-337-0365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number61164
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License NumberG61164
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberG61164
License Number StateCA

VIII. Authorized Official

Name: CRAIG SMITH
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 888-870-2201