Provider Demographics
NPI:1043377278
Name:CREATIVE LIVING ASSOCIATES
Entity type:Organization
Organization Name:CREATIVE LIVING ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR ASSOCIATE
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:REDIEHS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:704-788-9184
Mailing Address - Street 1:1001 E WT HARRIS BLVD
Mailing Address - Street 2:SUITE P-317
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-4104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 VANCE AVE
Practice Address - Street 2:
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28081-4339
Practice Address - Country:US
Practice Address - Phone:704-788-9184
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2296101YP2500X
NC526106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty