Healthcare Provider Details

I. General information

NPI: 1508294059
Provider Name (Legal Business Name): CREATIVE CARE 2
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2013
Last Update Date: 10/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6405 MIDDLEBELT RD
ROMULUS MI
48174-2036
US

IV. Provider business mailing address

6405 MIDDLEBELT RD
ROMULUS MI
48174-2036
US

V. Phone/Fax

Practice location:
  • Phone: 734-895-6505
  • Fax:
Mailing address:
  • Phone: 734-895-6505
  • 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: MS. DEVAN CLARK
Title or Position: OWNER
Credential:
Phone: 313-713-1018