Healthcare Provider Details

I. General information

NPI: 1528974003
Provider Name (Legal Business Name): THE CREATIVE PALACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2994 GALAHAD WAY
AUGUSTA GA
30909-9150
US

IV. Provider business mailing address

2994 GALAHAD WAY
AUGUSTA GA
30909-9150
US

V. Phone/Fax

Practice location:
  • Phone: 706-267-6037
  • Fax:
Mailing address:
  • Phone: 706-267-6037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: LATISHA HART
Title or Position: FOUNDER/CEO
Credential:
Phone: 706-267-6037