=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770727182
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INNOVATIVE COUNSELING LCSW PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2009
-----------------------------------------------------
Last Update Date | 09/14/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2127 CROMPOND RD STE 102
-----------------------------------------------------
City | CORTLANDT MANOR
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10567-4334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-788-8400
-----------------------------------------------------
Fax | 914-788-6781
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2127 CROMPOND RD STE 102
-----------------------------------------------------
City | CORTLANDT MANOR
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10567-4328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-788-8400
-----------------------------------------------------
Fax | 914-788-6781
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MRS. SANDRA SERRANO
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 914-788-8400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 73-069744
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------