Healthcare Provider Details

I. General information

NPI: 1306949896
Provider Name (Legal Business Name): INNOVATIVE PSYCHIATRIC CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 10/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 INGERSOLL AVE SUITE 108
DES MOINES IA
50312-3534
US

IV. Provider business mailing address

3900 INGERSOLL AVE SUITE 108
DES MOINES IA
50312-3534
US

V. Phone/Fax

Practice location:
  • Phone: 515-279-6200
  • Fax: 515-279-4528
Mailing address:
  • Phone: 515-279-6200
  • Fax: 515-279-4528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DR. LOREN A OLSON
Title or Position: OWNER
Credential: M.D.
Phone: 515-279-6200