Healthcare Provider Details

I. General information

NPI: 1639797657
Provider Name (Legal Business Name): INNOVATIVE SUPPORT SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2020
Last Update Date: 07/07/2020
Certification Date: 07/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8344 WOODBURY PIKE UNIT 101
ROARING SPRING PA
16673-8107
US

IV. Provider business mailing address

630 PLEASANT VALLEY BLVD STE C
ALTOONA PA
16602-4871
US

V. Phone/Fax

Practice location:
  • Phone: 814-934-4351
  • Fax: 814-201-2035
Mailing address:
  • Phone: 814-631-9477
  • Fax: 814-201-2035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. JODI BETH BISHOP
Title or Position: CEO
Credential:
Phone: 814-631-9477