Provider Demographics
NPI:1003814864
Name:INNOVATIVE THERAPY CONCEPTS, LLC
Entity Type:Organization
Organization Name:INNOVATIVE THERAPY CONCEPTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:216-441-6767
Mailing Address - Street 1:4900 E 97TH ST
Mailing Address - Street 2:
Mailing Address - City:GARFIELD HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44125-2122
Mailing Address - Country:US
Mailing Address - Phone:216-441-6767
Mailing Address - Fax:216-441-6767
Practice Address - Street 1:4900 E 97TH ST
Practice Address - Street 2:
Practice Address - City:GARFIELD HTS
Practice Address - State:OH
Practice Address - Zip Code:44125-2122
Practice Address - Country:US
Practice Address - Phone:216-441-6767
Practice Address - Fax:216-441-6767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-05000581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHDASW29571Medicare PIN
OHIN9355781Medicare PIN