Healthcare Provider Details

I. General information

NPI: 1316337967
Provider Name (Legal Business Name): INNOVATIVE THERAPEUTIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2015
Last Update Date: 02/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 N POTOMAC ST
HAGERSTOWN MD
21740-4855
US

IV. Provider business mailing address

14440 CHERRY LANE CT
LAUREL MD
20707-4946
US

V. Phone/Fax

Practice location:
  • Phone: 301-455-7872
  • Fax:
Mailing address:
  • Phone: 301-604-1458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MISTY CROMARTIE
Title or Position: CEO
Credential: LCPC
Phone: 301-455-7872