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General NPI Number Information
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NPI Number | 1184703670
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Entity Type | Organization
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Legal Business Name | CREATIVE LIFE SKILLS DEVELOPMENT
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Dates
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Enumeration Date | 11/03/2006
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Last Update Date | 09/07/2011
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Provider Practice Location Address
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Address Line | 15508 W BELL RD SUITE 101-261
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City | SURPRISE
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State | AZ
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Zip | 85374-2432
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Country | US
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Telephone | 602-441-5975
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Fax | 602-485-8859
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Provider Business Mailing Address
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Address Line | 15508 W BELL RD SUITE 101-261
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City | SURPRISE
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State | AZ
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Zip | 85374-2432
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Country | US
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Telephone | 602-441-5975
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Fax | 602-485-8859
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Authorized Official
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Title or Position | OWNER
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Name | MRS. LISA LYN HERRMANN
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Credential | M.S OTR/L
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Telephone | 602-441-5975
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251P0200X
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Taxonomy Name | Pediatric Physical Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 225XP0200X
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Taxonomy Name | Pediatric Occupational Therapist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | 2762
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License Number State | AZ
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Taxonomy #5
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Taxonomy Code | 261QD1600X
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Taxonomy Name | Developmental Disabilities Clinic/Center
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License Number |
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License Number State |
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