Healthcare Provider Details

I. General information

NPI: 1417308941
Provider Name (Legal Business Name): CREATIVE INDEPENDENT ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2016
Last Update Date: 07/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 INTERNATIONAL PLZ SUITE 550
PHILADELPHIA PA
19113-1510
US

IV. Provider business mailing address

1 INTERNATIONAL PLZ SUITE 550
PHILADELPHIA PA
19113-1510
US

V. Phone/Fax

Practice location:
  • Phone: 267-275-2393
  • Fax:
Mailing address:
  • Phone: 267-275-2393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number6417465
License Number StatePA

VIII. Authorized Official

Name: MS. PAMELAN PENDLETON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 267-275-2393