Healthcare Provider Details

I. General information

NPI: 1891067377
Provider Name (Legal Business Name): INNOVATIVE CAREER CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2012
Last Update Date: 01/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 W 23RD ST #206, 5TH FLOOR
NEW YORK NY
10011-2599
US

IV. Provider business mailing address

268 EDGEMONT TER
TEANECK NJ
07666-3404
US

V. Phone/Fax

Practice location:
  • Phone: 917-445-6323
  • Fax: 212-313-9439
Mailing address:
  • Phone: 917-445-6323
  • Fax: 212-313-9439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number000351-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number37RT00288300
License Number StateNJ

VIII. Authorized Official

Name: ROSA NELLY LAVERGNE
Title or Position: OWNER
Credential: PH.D.
Phone: 917-445-6323