Provider Demographics
NPI:1265192413
Name:CREATIVE PRACTICE, LLC
Entity type:Organization
Organization Name:CREATIVE PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDAYSHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:TANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-238-1924
Mailing Address - Street 1:1202 MAIN ST STE 202
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-5057
Mailing Address - Country:US
Mailing Address - Phone:501-238-1924
Mailing Address - Fax:501-491-0026
Practice Address - Street 1:1202 MAIN ST STE 202
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-5057
Practice Address - Country:US
Practice Address - Phone:501-238-1924
Practice Address - Fax:501-491-0026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-28
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health