Healthcare Provider Details

I. General information

NPI: 1790309904
Provider Name (Legal Business Name): CREATIVE HEALTH CARE MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2020
Last Update Date: 12/21/2020
Certification Date: 12/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 INTERCHANGE RD S STE A
EVANSVILLE IN
47715-8210
US

IV. Provider business mailing address

10 S 9TH ST STE 4
NOBLESVILLE IN
46060-2631
US

V. Phone/Fax

Practice location:
  • Phone: 812-477-5000
  • Fax:
Mailing address:
  • Phone: 765-524-3946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: JESSICA BEAUDRY
Title or Position: VP OF OPERATIONS
Credential:
Phone: 765-623-6599