Healthcare Provider Details

I. General information

NPI: 1093522807
Provider Name (Legal Business Name): CREEKSIDE PEDIATRIC THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2024
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 GOODYEAR BLVD
PICAYUNE MS
39466-3307
US

IV. Provider business mailing address

141 N HILL DR
CARRIERE MS
39426-8129
US

V. Phone/Fax

Practice location:
  • Phone: 601-215-3267
  • Fax: 601-255-8626
Mailing address:
  • Phone: 601-215-3267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: HEIDI MOLAISON
Title or Position: OCCUPATIONAL THERAPIST/OWNER
Credential:
Phone: 985-232-2832