Provider Demographics
NPI:1306084991
Name:CREATIVE ONE STUDIO, INC.
Entity type:Organization
Organization Name:CREATIVE ONE STUDIO, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROFESSIONAL COUNSELOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:PUALANI
Authorized Official - Last Name:TAKAKI
Authorized Official - Suffix:
Authorized Official - Credentials:BC-DMT, LCPC
Authorized Official - Phone:773-318-7331
Mailing Address - Street 1:501 S HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:VILLA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60181-2808
Mailing Address - Country:US
Mailing Address - Phone:773-318-7331
Mailing Address - Fax:
Practice Address - Street 1:501 S HARVARD AVE
Practice Address - Street 2:
Practice Address - City:VILLA PARK
Practice Address - State:IL
Practice Address - Zip Code:60181-2808
Practice Address - Country:US
Practice Address - Phone:773-318-7331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-04
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180006573251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health