Provider Demographics
NPI:1295928075
Name:CREATIVE DEVELOPMENT, LLC
Entity type:Organization
Organization Name:CREATIVE DEVELOPMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:860-284-9779
Mailing Address - Street 1:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-0421
Mailing Address - Country:US
Mailing Address - Phone:860-284-9779
Mailing Address - Fax:860-409-2190
Practice Address - Street 1:30 AVON MEADOW LN
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3745
Practice Address - Country:US
Practice Address - Phone:860-833-9905
Practice Address - Fax:860-409-2190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-24
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001742235Z00000X
CT000957174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008047516Medicaid