Healthcare Provider Details

I. General information

NPI: 1124389010
Provider Name (Legal Business Name): CREATIVE FAMILY SERVICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2012
Last Update Date: 05/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4222 W CAPITOL DR
MILWAUKEE WI
53216-2500
US

IV. Provider business mailing address

4620 W CONCORDIA AVE
MILWAUKEE WI
53216-3350
US

V. Phone/Fax

Practice location:
  • Phone: 414-388-8293
  • Fax: 414-249-4658
Mailing address:
  • Phone: 414-388-8293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number16594-130
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: MRS. ANDREA WARD
Title or Position: EXECUTIVE DIRECTOR
Credential: COUNSELOR/CASE MANAG
Phone: 414-388-8293