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General NPI Number Information
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NPI Number | 1982043394
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Entity Type | Organization
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Legal Business Name | INNOVATIVE THERAPY SERVICES, LLC
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Dates
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Enumeration Date | 06/19/2013
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Last Update Date | 02/16/2015
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Provider Practice Location Address
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Address Line | 3939 W RIDGE RD SUITE B-45
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City | ERIE
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State | PA
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Zip | 16506-1879
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Country | US
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Telephone | 814-240-1011
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Fax | 814-240-1048
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Provider Business Mailing Address
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Address Line | 3939 W RIDGE RD SUITE B-45
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City | ERIE
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State | PA
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Zip | 16506-1879
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Country | US
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Telephone | 814-240-1011
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Fax | 814-240-1048
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Authorized Official
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Title or Position | PARTNER
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Name | SHANA LYNN BENNETT
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Credential | LCSW
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Telephone | 814-240-1011
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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 | PC005212
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | CW016017
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License Number State | PA
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