Healthcare Provider Details

I. General information

NPI: 1336013986
Provider Name (Legal Business Name): CREATIVE MIND HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2025
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10901 W 84TH TER
OVERLAND PARK KS
66214-1649
US

IV. Provider business mailing address

10420 S RIDGEVIEW RD UNIT 2069
OLATHE KS
66061-6438
US

V. Phone/Fax

Practice location:
  • Phone: 913-395-3300
  • Fax:
Mailing address:
  • Phone: 913-395-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: MS. JESSICA L WATERS
Title or Position: CLINICAL SUPERVISOR
Credential: LCAC, LADC, ADDC
Phone: 913-395-3300