Healthcare Provider Details

I. General information

NPI: 1861263204
Provider Name (Legal Business Name): INNOVATIVE PSYCHOLOGICAL SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2024
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3842 LEEDS AVE UNIT B
NORTH CHARLESTON SC
29405-7460
US

IV. Provider business mailing address

525 CABRILLO PARK DR STE 105
SANTA ANA CA
92701-5017
US

V. Phone/Fax

Practice location:
  • Phone: 843-990-3701
  • Fax:
Mailing address:
  • Phone: 714-617-4616
  • Fax: 714-617-4508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY BROOKS
Title or Position: PSYCHOLOGIST/PRESIDENT
Credential: PSYD
Phone: 843-990-3701