MEDICARE: INNOVATIVE INTERVENTIONS FOR OUR COMMUNITIES

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

General Provider Information

NPI Number	:	1700692605
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE INTERVENTIONS FOR OUR COMMUNITIES

Provider Business Mailing Address
First Line	:	2829 ALLEN RD S
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-4609
Country	:	US
Telephone Number	:	704-430-6394
Fax Number	:

Provider Business Practice Location Address
First Line	:	2829 ALLEN RD S
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-4609
Country	:	US
Telephone Number	:	704-430-6394
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LATOYA THOMAS
Credential	:	LCSW
Telephone Number	:	704-430-6394

Provider Enumeration Date	:	12/05/2024
Last Update Date	:	12/05/2024

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