Provider Demographics
NPI:1134460363
Name:INNOVATIVE THERAPY SERVICES
Entity Type:Organization
Organization Name:INNOVATIVE THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH PATHOLOGIST
Authorized Official - Prefix:MS
Authorized Official - First Name:TASHA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:WINNS
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:301-646-0304
Mailing Address - Street 1:632 TAHOE CIR
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-4450
Mailing Address - Country:US
Mailing Address - Phone:301-646-0304
Mailing Address - Fax:
Practice Address - Street 1:632 TAHOE CIR
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-4450
Practice Address - Country:US
Practice Address - Phone:301-646-0304
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-13
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007594252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency