Healthcare Provider Details

I. General information

NPI: 1457743981
Provider Name (Legal Business Name): CREATIVE KIDS THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2015
Last Update Date: 02/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24941 AMERICA CENTER RD
CUSTER SD
57730-8335
US

IV. Provider business mailing address

24941 AMERICA CENTER RD
CUSTER SD
57730-8335
US

V. Phone/Fax

Practice location:
  • Phone: 701-367-4736
  • Fax:
Mailing address:
  • Phone: 701-367-4736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number0750
License Number StateSD

VIII. Authorized Official

Name: SUSAN HANS
Title or Position: OWNER/OCCUPATIONAL THERAPIST
Credential: OTR/L
Phone: 701-367-4736