Provider Demographics
NPI:1215398334
Name:INNOVATIVE PSYCHIATRY LLC
Entity Type:Organization
Organization Name:INNOVATIVE PSYCHIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANANDRAJ
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:443-542-0773
Mailing Address - Street 1:8850 COLUMBIA 100 PKWY
Mailing Address - Street 2:SUITE 403
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-2374
Mailing Address - Country:US
Mailing Address - Phone:443-542-0773
Mailing Address - Fax:443-542-0931
Practice Address - Street 1:8850 COLUMBIA 100 PKWY
Practice Address - Street 2:SUITE 403
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-2374
Practice Address - Country:US
Practice Address - Phone:443-542-0773
Practice Address - Fax:443-542-0931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-17
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD676682084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty