Healthcare Provider Details

I. General information

NPI: 1881103224
Provider Name (Legal Business Name): INNOVATIVE BEHAVIORAL HEALTH SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26750 S DIXIE HWY
HOMESTEAD FL
33032-7431
US

IV. Provider business mailing address

1938 SE 22ND CT
HOMESTEAD FL
33035-1238
US

V. Phone/Fax

Practice location:
  • Phone: 786-712-2314
  • Fax:
Mailing address:
  • Phone: 786-712-2314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: LUCKNER C DENORD
Title or Position: PRESIDENT AND CEO
Credential:
Phone: 786-712-2314