Provider Demographics
NPI:1124367347
Name:INNOVATIVE BEHAVIORAL HEALTH SERVICES P.C.
Entity Type:Organization
Organization Name:INNOVATIVE BEHAVIORAL HEALTH SERVICES P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MASTRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, PMHNP-BC
Authorized Official - Phone:919-529-2474
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:CREEDMOOR
Mailing Address - State:NC
Mailing Address - Zip Code:27522-0400
Mailing Address - Country:US
Mailing Address - Phone:919-529-2474
Mailing Address - Fax:
Practice Address - Street 1:402 MAIN ST
Practice Address - Street 2:
Practice Address - City:CREEDMOOR
Practice Address - State:NC
Practice Address - Zip Code:27522
Practice Address - Country:US
Practice Address - Phone:919-529-2474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-07
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty