Provider Demographics
NPI:1316577307
Name:INTERACTIVE CREATIVE THERAPY INC
Entity type:Organization
Organization Name:INTERACTIVE CREATIVE THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DECHANTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTANO
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:580-402-6704
Mailing Address - Street 1:25 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-6101
Mailing Address - Country:US
Mailing Address - Phone:631-790-2584
Mailing Address - Fax:
Practice Address - Street 1:18 W 21ST ST
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-3918
Practice Address - Country:US
Practice Address - Phone:631-306-4053
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-19
Last Update Date:2020-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty