Healthcare Provider Details

I. General information

NPI: 1508034315
Provider Name (Legal Business Name): INNOVATIVE THEARPY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2008
Last Update Date: 02/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 W CLEVELAND RD. B23
GRANGER IN
46530
US

IV. Provider business mailing address

54658 OAK LEAF CT
MISHAWAKA IN
46545-1862
US

V. Phone/Fax

Practice location:
  • Phone: 574-243-9640
  • Fax: 574-243-9640
Mailing address:
  • Phone: 574-255-1712
  • Fax: 574-255-4840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05003216
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: GLENDA M BROWN
Title or Position: PT
Credential:
Phone: 574-255-1712