Provider Demographics
NPI:1508100819
Name:INNOVATIVE COUNSELING LLC
Entity Type:Organization
Organization Name:INNOVATIVE COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:SMIALEK
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:813-838-3074
Mailing Address - Street 1:7251 SR 54,PMB 205
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544
Mailing Address - Country:US
Mailing Address - Phone:813-322-3850
Mailing Address - Fax:
Practice Address - Street 1:25251 SR 54,PMB 205
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544
Practice Address - Country:US
Practice Address - Phone:813-322-3850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH9288101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty