Provider Demographics
NPI:1326249434
Name:INNOVATIVE COMMUNITY RESOURCES NC INC
Entity Type:Organization
Organization Name:INNOVATIVE COMMUNITY RESOURCES NC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:I
Authorized Official - Last Name:TILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:704-921-6777
Mailing Address - Street 1:5736 N TRYON ST STE 200
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-0820
Mailing Address - Country:US
Mailing Address - Phone:704-921-6777
Mailing Address - Fax:704-509-2220
Practice Address - Street 1:5736 N TRYON ST STE 200
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28213-0820
Practice Address - Country:US
Practice Address - Phone:704-921-6777
Practice Address - Fax:704-509-2220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3411101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty