Provider Demographics
NPI:1508034315
Name:INNOVATIVE THEARPY SERVICES
Entity Type:Organization
Organization Name:INNOVATIVE THEARPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT
Authorized Official - Prefix:
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-255-1712
Mailing Address - Street 1:54658 OAK LEAF CT
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-1862
Mailing Address - Country:US
Mailing Address - Phone:574-255-1712
Mailing Address - Fax:574-255-4840
Practice Address - Street 1:430 W CLEVELAND RD.
Practice Address - Street 2:B23
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530
Practice Address - Country:US
Practice Address - Phone:574-243-9640
Practice Address - Fax:574-243-9640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05003216225100000X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty