MEDICARE: INNOVATIVE THERAPY CONCEPTS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	I-0500058	OH

General Provider Information

NPI Number	:	1003814864
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE THERAPY CONCEPTS, LLC

Provider Business Mailing Address
First Line	:	4900 E 97TH ST
Second Line	:
City	:	GARFIELD HTS
State	:	OH
Zip	:	44125-2122
Country	:	US
Telephone Number	:	216-441-6767
Fax Number	:	216-441-6767

Provider Business Practice Location Address
First Line	:	4900 E 97TH ST
Second Line	:
City	:	GARFIELD HTS
State	:	OH
Zip	:	44125-2122
Country	:	US
Telephone Number	:	216-441-6767
Fax Number	:	216-441-6767

Authorized Official
Title or Position	:	PSYCHOTHERAPIST/OWNER
Name	:	MR. SEAN L. DAVIS
Credential	:	LISW
Telephone Number	:	216-441-6767

Provider Enumeration Date	:	07/14/2005
Last Update Date	:	08/22/2020

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