=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497219653
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INNOVATIVE FAMILY THERAPY & PLAY THERAPY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2019
-----------------------------------------------------
Last Update Date | 01/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 409 N 4TH ST STE 108
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52601-5255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-759-9414
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 12
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52601-0012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-759-9414
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/LMFT
-----------------------------------------------------
Name | THERESA RECKLING
-----------------------------------------------------
Credential | MA, LMFT, RPT
-----------------------------------------------------
Telephone | 319-759-9414
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------