Healthcare Provider Details

I. General information

NPI: 1891820130
Provider Name (Legal Business Name): CREATIVE COMMUNITY SERVICE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 05/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4487 PARK DR SUITE A
NORCROSS GA
30093-2964
US

IV. Provider business mailing address

4487 PARK DR SUITE A
NORCROSS GA
30093-2964
US

V. Phone/Fax

Practice location:
  • Phone: 770-469-6226
  • Fax: 678-894-4081
Mailing address:
  • Phone: 770-469-6226
  • Fax: 678-894-4081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number060-R-0018
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number060-R-0018
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberCP-FC0040079
License Number StateGA

VIII. Authorized Official

Name: MS. CATHY PALLON
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 770-469-6226