=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811641277
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INNOVATIVE THERAPISTS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2022
-----------------------------------------------------
Last Update Date | 02/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 309 N MARKET ST
-----------------------------------------------------
City | SOMERSET
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43783-9414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-405-5001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 309 N MARKET ST
-----------------------------------------------------
City | SOMERSET
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43783-9414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-405-8053
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/THERAPIST
-----------------------------------------------------
Name | SHANNON E FRAME
-----------------------------------------------------
Credential | LISW-S, LICDC-CS
-----------------------------------------------------
Telephone | 740-405-8053
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------