MEDICARE: INNOVATIVE BEHAVIORAL THERAPY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1912510868
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE BEHAVIORAL THERAPY, LLC

Provider Business Mailing Address
First Line	:	915 MAIN ST
Second Line	:
City	:	ADEL
State	:	IA
Zip	:	50003-1452
Country	:	US
Telephone Number	:	712-899-3559
Fax Number	:

Provider Business Practice Location Address
First Line	:	915 MAIN ST
Second Line	:
City	:	ADEL
State	:	IA
Zip	:	50003-1452
Country	:	US
Telephone Number	:	712-899-3559
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ASHLEY ANDREW
Credential	:
Telephone Number	:	712-899-3559

Provider Enumeration Date	:	08/28/2020
Last Update Date	:	08/28/2020

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