Provider Demographics
NPI:1902593015
Name:CREEKSIDE THERAPEUTICS
Entity type:Organization
Organization Name:CREEKSIDE THERAPEUTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, BCBA
Authorized Official - Phone:434-515-2041
Mailing Address - Street 1:137 LAXTON RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-5294
Mailing Address - Country:US
Mailing Address - Phone:434-515-2041
Mailing Address - Fax:
Practice Address - Street 1:137 LAXTON RD STE 200
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-5294
Practice Address - Country:US
Practice Address - Phone:434-515-2041
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-19
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30017547490002Medicaid