Healthcare Provider Details

I. General information

NPI: 1184923054
Provider Name (Legal Business Name): INNOVATIVE SUPPORT SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2011
Last Update Date: 03/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 MODEST ST
LAKELAND FL
33805-3123
US

IV. Provider business mailing address

PO BOX 2253
EATON PARK FL
33840-2253
US

V. Phone/Fax

Practice location:
  • Phone: 863-904-8820
  • Fax: 866-271-5349
Mailing address:
  • Phone: 863-904-8820
  • Fax: 866-271-5349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: STEPHANIE KIRNES
Title or Position: EXECUTIVE DIRECTOR
Credential: MA, CMHP
Phone: 863-904-8820