Healthcare Provider Details

I. General information

NPI: 1295928075
Provider Name (Legal Business Name): CREATIVE DEVELOPMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2007
Last Update Date: 04/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 AVON MEADOW LN
AVON CT
06001-3745
US

IV. Provider business mailing address

PO BOX 421
AVON CT
06001-0421
US

V. Phone/Fax

Practice location:
  • Phone: 860-833-9905
  • Fax: 860-409-2190
Mailing address:
  • Phone: 860-284-9779
  • Fax: 860-409-2190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number000957
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number001742
License Number StateCT

VIII. Authorized Official

Name: DEANNE ANDERSON
Title or Position: MANAGING MEMBER
Credential: OTR/L
Phone: 860-284-9779