Healthcare Provider Details

I. General information

NPI: 1285244723
Provider Name (Legal Business Name): MICHAEL SCOTT CREEKPAUM PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2020
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5755 COTTLE RD BLDG 23
SAN JOSE CA
95123-3600
US

IV. Provider business mailing address

PO BOX 53166
SAN JOSE CA
95153-0166
US

V. Phone/Fax

Practice location:
  • Phone: 408-972-3095
  • Fax:
Mailing address:
  • Phone: 408-624-7882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY36113
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: