Healthcare Provider Details

I. General information

NPI: 1639666837
Provider Name (Legal Business Name): CREATIVE WELLNESS INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2018
Last Update Date: 04/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1713 E WALNUT ST
PASADENA CA
91106-1611
US

IV. Provider business mailing address

4001 DON TOMASO DR APT 1
LOS ANGELES CA
90008-5319
US

V. Phone/Fax

Practice location:
  • Phone: 602-299-4679
  • Fax:
Mailing address:
  • Phone: 602-299-4679
  • 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 TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CECCILY BEDNASH
Title or Position: PRESIDENT
Credential:
Phone: 602-299-4679