Healthcare Provider Details

I. General information

NPI: 1003814864
Provider Name (Legal Business Name): INNOVATIVE THERAPY CONCEPTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 E 97TH ST
GARFIELD HTS OH
44125-2122
US

IV. Provider business mailing address

4900 E 97TH ST
GARFIELD HTS OH
44125-2122
US

V. Phone/Fax

Practice location:
  • Phone: 216-441-6767
  • Fax: 216-441-6767
Mailing address:
  • Phone: 216-441-6767
  • Fax: 216-441-6767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-0500058
License Number StateOH

VIII. Authorized Official

Name: MR. SEAN L. DAVIS
Title or Position: PSYCHOTHERAPIST/OWNER
Credential: LISW
Phone: 216-441-6767