MEDICARE: CREATIVE LIFE SKILLS DEVELOPMENT, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	2762	AZ

General Provider Information

NPI Number	:	1598983710
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CREATIVE LIFE SKILLS DEVELOPMENT, INC

Provider Business Mailing Address
First Line	:	PO BOX 71726
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85050-1013
Country	:	US
Telephone Number	:	602-441-5975
Fax Number	:	602-485-8859

Provider Business Practice Location Address
First Line	:	1941 E WESCOTT DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85024-2434
Country	:	US
Telephone Number	:	602-441-5975
Fax Number	:	602-485-8859

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. LISA LYN HERRMANN
Credential	:	MS OTR
Telephone Number	:	602-441-5975

Provider Enumeration Date	:	04/23/2007
Last Update Date	:	08/22/2020

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