MEDICARE: INNOVATIVE PSYCHOLOGY SERVICES, 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	103TC0700X	Clinical Psychologist	2456-057	WI

General Provider Information

NPI Number	:	1063609584
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE PSYCHOLOGY SERVICES, LLC

Provider Business Mailing Address
First Line	:	7635 W OKLAHOMA AVE
Second Line	:	SUITE 214
City	:	MILWAUKEE
State	:	WI
Zip	:	53219-3600
Country	:	US
Telephone Number	:	414-732-3172
Fax Number	:	414-386-4632

Provider Business Practice Location Address
First Line	:	7635 W OKLAHOMA AVE
Second Line	:	SUITE 214
City	:	MILWAUKEE
State	:	WI
Zip	:	53219-3600
Country	:	US
Telephone Number	:	414-732-3172
Fax Number	:	414-386-4632

Authorized Official
Title or Position	:	PSYCHOLOGIST
Name	:	DR. BRENDA REED
Credential	:	PSY.D.
Telephone Number	:	414-732-3172

Provider Enumeration Date	:	09/28/2007
Last Update Date	:	09/28/2007

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