Healthcare Provider Details

I. General information

NPI: 1619623154
Provider Name (Legal Business Name): CREATIVE ABA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2022
Last Update Date: 02/25/2022
Certification Date: 02/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3720 GLENVIEW CIR
MODESTO CA
95355-1309
US

IV. Provider business mailing address

3720 GLENVIEW CIR
MODESTO CA
95355-1309
US

V. Phone/Fax

Practice location:
  • Phone: 209-408-9922
  • Fax:
Mailing address:
  • Phone: 209-408-9922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ALEXIS ROSE WINTERS
Title or Position: CLINICAL DIRECTOR
Credential: BCBA
Phone: 209-408-9992