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General NPI Number Information
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NPI Number | 1942651724
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Entity Type | Organization
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Legal Business Name | INNOVATIVE CONCEPTS
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Dates
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Enumeration Date | 06/23/2016
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Last Update Date | 03/11/2024
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Provider Practice Location Address
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Address Line | 9625 DAVID TAYLOR DR # 120A
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City | CHARLOTTE
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State | NC
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Zip | 28262-2362
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Country | US
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Telephone | 704-533-5168
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Fax |
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Provider Business Mailing Address
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Address Line | 133 WEAVERS GLENN PL
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City | CHARLOTTE
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State | NC
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Zip | 28262-1698
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Country | US
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Telephone | 704-533-5168
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | NADINE ROBERTS
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Credential | LCMHC
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Telephone | 704-533-5168
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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 | A12126
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License Number State | NC
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