=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770880890
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CREATIVE CARE HEALTH CONCEPTS,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2011
-----------------------------------------------------
Last Update Date | 04/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1943 SAYBROOK CT
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30236-2681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-478-6091
-----------------------------------------------------
Fax | 770-478-6875
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1943 SAYBROOK CT
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30236-2681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-478-6091
-----------------------------------------------------
Fax | 770-478-6875
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT AND CEO
-----------------------------------------------------
Name | MS. KAREN MARION CHEESEMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-478-6091
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 364SP0813X
-----------------------------------------------------
Taxonomy Name | Geropsychiatric Psychiatric/Mental Health Clinical Nurse Specialist
-----------------------------------------------------
License Number | 10086641
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------