=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174768360
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INNOVATIVE THERAPIES GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2008
-----------------------------------------------------
Last Update Date | 10/03/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 929 HWY 27/441 UNIT 301
-----------------------------------------------------
City | LADY LAKE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32159-3002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-433-0091
-----------------------------------------------------
Fax | 352-433-0676
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 929 HWY 27/441 UNIT 301
-----------------------------------------------------
City | LADY LAKE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32159-3002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-433-0091
-----------------------------------------------------
Fax | 352-433-0676
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. KIMBERLY A LANCASTER
-----------------------------------------------------
Credential | OTR/L
-----------------------------------------------------
Telephone | 352-216-1911
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT 00330
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225XH1200X
-----------------------------------------------------
Taxonomy Name | Hand Occupational Therapist
-----------------------------------------------------
License Number | OT 4267
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SA 2999
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT 4267
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------