Healthcare Provider Details

I. General information

NPI: 1093367633
Provider Name (Legal Business Name): INNOVATIVE BEHAVIORAL MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2019
Last Update Date: 07/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 PENN CENTER BLVD STE 457
PITTSBURGH PA
15235-5435
US

IV. Provider business mailing address

201 PENN CENTER BLVD STE 457
PITTSBURGH PA
15235-5435
US

V. Phone/Fax

Practice location:
  • Phone: 412-439-1251
  • Fax: 412-291-3003
Mailing address:
  • Phone: 412-439-1251
  • Fax: 412-291-3003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER J GOISSE
Title or Position: CFO
Credential: MBA
Phone: 724-984-8645