Healthcare Provider Details

I. General information

NPI: 1538654900
Provider Name (Legal Business Name): CREATING 2ND CHANCES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2018
Last Update Date: 01/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 NE SPRING CREEK PL
LEES SUMMIT MO
64086-7089
US

IV. Provider business mailing address

508 NE SPRING CREEK PL
LEES SUMMIT MO
64086-7089
US

V. Phone/Fax

Practice location:
  • Phone: 816-223-4267
  • Fax:
Mailing address:
  • Phone: 816-679-0914
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
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: MRS. ERICA LYNN THOMPSON
Title or Position: OWNER/FAMILY SERVICES SPECIALIST
Credential: LPC
Phone: 816-679-0914