Healthcare Provider Details

I. General information

NPI: 1558177659
Provider Name (Legal Business Name): CREATIVE OPPORTUNITIES FOR PERSONAL EMPOWERMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2024
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 CONCORD PKWY N UNIT 5649
CONCORD NC
28027-6749
US

IV. Provider business mailing address

PO BOX 5649
CONCORD NC
28027-1510
US

V. Phone/Fax

Practice location:
  • Phone: 704-247-7111
  • Fax:
Mailing address:
  • Phone: 704-247-7111
  • 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
# 4
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. TIFFANY GRAHAM
Title or Position: CHIEF CLINICAL OFFICER
Credential: MA, LCMHC, LCASA
Phone: 704-247-7111