Provider Demographics
NPI:1699078659
Name:CREA, JAMES MARK (CDP)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:MARK
Last Name:CREA
Suffix:
Gender:M
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 N 3RD STREET
Mailing Address - Street 2:
Mailing Address - City:MONTESANO
Mailing Address - State:WA
Mailing Address - Zip Code:98563
Mailing Address - Country:US
Mailing Address - Phone:360-593-7030
Mailing Address - Fax:
Practice Address - Street 1:2502 TACOMA AVE S
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402
Practice Address - Country:US
Practice Address - Phone:253-759-0852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-14
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP 00006301171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACP 00006301OtherCHEMICAL DEPENDENCY PROFESSIONAL CERTIFACATION NUMBER