Provider Demographics
NPI:1568175867
Name:INNOVATIVE TREATMENT CENTERS
Entity Type:Organization
Organization Name:INNOVATIVE TREATMENT CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:ALDEN
Authorized Official - Last Name:BAIRD
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:443-430-2998
Mailing Address - Street 1:325 HOSPITAL DR STE 106
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-5806
Mailing Address - Country:US
Mailing Address - Phone:917-873-5716
Mailing Address - Fax:
Practice Address - Street 1:325 HOSPITAL DR STE 106
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-5806
Practice Address - Country:US
Practice Address - Phone:443-430-2998
Practice Address - Fax:443-431-8978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-02
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD699298600Medicaid