Provider Demographics
NPI:1861604142
Name:CREEKSIDE CHILD DEVELOPMENT SERVICES INC
Entity type:Organization
Organization Name:CREEKSIDE CHILD DEVELOPMENT SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF AGENCY AND SOLE PROPRI
Authorized Official - Prefix:MRS
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HATTON
Authorized Official - Suffix:
Authorized Official - Credentials:DI DEVELOPMENTAL INT
Authorized Official - Phone:606-663-3690
Mailing Address - Street 1:1120 BRUSH CREEK ROAD
Mailing Address - Street 2:
Mailing Address - City:CLAY CITY
Mailing Address - State:KY
Mailing Address - Zip Code:40312
Mailing Address - Country:US
Mailing Address - Phone:606-663-3690
Mailing Address - Fax:606-663-3690
Practice Address - Street 1:1120 BRUSH CREEK ROAD
Practice Address - Street 2:
Practice Address - City:CLAY CITY
Practice Address - State:KY
Practice Address - Zip Code:40312
Practice Address - Country:US
Practice Address - Phone:606-663-3690
Practice Address - Fax:606-663-3690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities