Healthcare Provider Details

I. General information

NPI: 1033958715
Provider Name (Legal Business Name): INNOVATIVE THERAPY WORKS LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2024
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2959 CHEROKEE ST NW
KENNESAW GA
30144-6521
US

IV. Provider business mailing address

29 TIMBERLAND TRACE CT
DALLAS GA
30157-9669
US

V. Phone/Fax

Practice location:
  • Phone: 901-691-5954
  • Fax:
Mailing address:
  • Phone: 901-691-5954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. KENYA T JONES
Title or Position: PRACTICE MANAGER
Credential: LCSW
Phone: 901-691-5954