=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679916316
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INNOVATIVE OPTIONS INCORPORATED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2013
-----------------------------------------------------
Last Update Date | 04/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2016 SANDTOWN RD SW
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30311-3420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-237-8460
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2016 SANDTOWN RD SW
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30311-3420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-237-8460
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | MRS. ANTOINETTE NUMITAL THORNTON
-----------------------------------------------------
Credential | LCSW, CSAC, CSOTP
-----------------------------------------------------
Telephone | 757-237-8460
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------