Healthcare Provider Details

I. General information

NPI: 1972129948
Provider Name (Legal Business Name): INNOVATE BEHAVIORAL HEALTH MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2020
Last Update Date: 02/17/2023
Certification Date: 02/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

732 N MOUNTAIN AVE STE A
UPLAND CA
91786-4372
US

IV. Provider business mailing address

732 N MOUNTAIN AVE STE A
UPLAND CA
91786-4372
US

V. Phone/Fax

Practice location:
  • Phone: 909-579-2555
  • Fax: 909-579-2118
Mailing address:
  • Phone:
  • Fax: 909-727-8225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: HENRY HTEWLAY KHIN
Title or Position: OWNER
Credential: MD
Phone: 909-579-2555