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General NPI Number Information
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NPI Number | 1649637422
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Entity Type | Organization
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Legal Business Name | INNOVATIVE BEHAVIORAL HEALTH LLC
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Dates
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Enumeration Date | 01/25/2016
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Last Update Date | 01/25/2016
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Provider Practice Location Address
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Address Line | 2370 S KERR BLVD
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City | SALLISAW
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State | OK
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Zip | 74955-7031
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Country | US
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Telephone | 479-461-5275
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Fax |
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Provider Business Mailing Address
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Address Line | 3308 S 54TH ST
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City | FORT SMITH
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State | AR
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Zip | 72903-4617
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Country | US
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Telephone | 479-461-5275
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DAVID BOURNE
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Credential | LPC
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Telephone | 479-461-5275
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 4216
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License Number State | OK
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