Provider Demographics
NPI:1982999363
Name:CREIGHTON, EDWARD (LCSW)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:CREIGHTON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8133 268TH ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:FLORAL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11004-1545
Mailing Address - Country:US
Mailing Address - Phone:718-347-4587
Mailing Address - Fax:
Practice Address - Street 1:9729 64TH RD
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2259
Practice Address - Country:US
Practice Address - Phone:718-896-3400
Practice Address - Fax:718-459-5621
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0760111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00244019Medicaid