Provider Demographics
NPI:1548745391
Name:INNOVATIVE BEHAVIORAL HEALTH COUNSELING
Entity Type:Organization
Organization Name:INNOVATIVE BEHAVIORAL HEALTH COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLEY
Authorized Official - Middle Name:DEDRAETTE
Authorized Official - Last Name:HART-OGBURN
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:216-507-0168
Mailing Address - Street 1:3344 CEDARBROOK RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-2944
Mailing Address - Country:US
Mailing Address - Phone:216-507-0168
Mailing Address - Fax:
Practice Address - Street 1:3344 CEDARBROOK RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44118-2944
Practice Address - Country:US
Practice Address - Phone:216-507-0168
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH247366Medicaid