MEDICARE: INNOVATIVE CONCEPTS

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	101YP2500X	Professional Counselor	A12126	NC

General Provider Information

NPI Number	:	1942651724
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE CONCEPTS

Provider Business Mailing Address
First Line	:	133 WEAVERS GLENN PL
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-1698
Country	:	US
Telephone Number	:	704-533-5168
Fax Number	:

Provider Business Practice Location Address
First Line	:	9625 DAVID TAYLOR DR # 120A
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-2362
Country	:	US
Telephone Number	:	704-533-5168
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	NADINE ROBERTS
Credential	:	LCMHC
Telephone Number	:	704-533-5168

Provider Enumeration Date	:	06/23/2016
Last Update Date	:	03/11/2024

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Directions to “INNOVATIVE CONCEPTS ” Practice Location

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