MEDICARE: CREATIVE WELLNESS INSTITUTE

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	251S00000X	Community/Behavioral Health Agency
2	252Y00000X	Early Intervention Provider Agency
3	261QD1600X	Developmental Disabilities Clinic/Center
4	261QM0850X	Adult Mental Health Clinic/Center
5	261QR0400X	Rehabilitation Clinic/Center
6	261QM0855X	Adolescent and Children Mental Health Clinic/Center

General Provider Information

NPI Number	:	1639666837
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CREATIVE WELLNESS INSTITUTE

Provider Business Mailing Address
First Line	:	4001 DON TOMASO DR APT 1
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90008-5319
Country	:	US
Telephone Number	:	602-299-4679
Fax Number	:

Provider Business Practice Location Address
First Line	:	1713 E WALNUT ST
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91106-1611
Country	:	US
Telephone Number	:	602-299-4679
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CECCILY BEDNASH
Credential	:
Telephone Number	:	602-299-4679

Provider Enumeration Date	:	04/13/2018
Last Update Date	:	04/13/2018

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