Healthcare Provider Details

I. General information

NPI: 1174393771
Provider Name (Legal Business Name): CREATIVE HEALING SPACE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2024
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 EMMETT ST
FALL RIVER MA
02721-3523
US

IV. Provider business mailing address

875 STATE RD UNIT 11 #126
WESTPORT MA
02790-2853
US

V. Phone/Fax

Practice location:
  • Phone: 774-264-3481
  • Fax:
Mailing address:
  • Phone: 774-264-3481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JESSICA BARABY
Title or Position: OWNER
Credential: LICSW
Phone: 774-264-1249