Healthcare Provider Details

I. General information

NPI: 1871367185
Provider Name (Legal Business Name): INNOVATION THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2023
Last Update Date: 11/08/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 E VAN TREES ST
WASHINGTON IN
47501-2943
US

IV. Provider business mailing address

15532 US HIGHWAY 231
LOOGOOTEE IN
47553-4942
US

V. Phone/Fax

Practice location:
  • Phone: 812-698-5422
  • Fax: 877-389-9006
Mailing address:
  • Phone: 812-709-9129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ADRIA HAWTHORNE
Title or Position: OWNER, OCCUPATIONAL THERAPIST
Credential: MSOT, OTR
Phone: 812-698-5422