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General NPI Number Information
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NPI Number | 1790103828
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Entity Type | Organization
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Legal Business Name | INNOVATION AVENUE CONSULTING LLC
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Dates
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Enumeration Date | 04/05/2014
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Last Update Date | 04/05/2014
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Provider Practice Location Address
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Address Line | 606 DAVIDSON CT
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City | SAINT PETERS
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State | MO
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Zip | 63376-2472
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Country | US
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Telephone | 314-246-9249
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1721
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City | SAINT PETERS
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State | MO
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Zip | 63376-0050
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | LEAD COUNSELOR
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Name | KENYOTA MARIA DOKES
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Credential | MA. LPC
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Telephone | 314-502-9682
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 2012005837
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License Number State | MO
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