Provider Demographics
NPI:1568906394
Name:BEHAVIORAL INNOVATIONS THERAPY, LLC
Entity Type:Organization
Organization Name:BEHAVIORAL INNOVATIONS THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:843-834-2656
Mailing Address - Street 1:328 GLEN ST
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-4653
Mailing Address - Country:US
Mailing Address - Phone:843-834-2656
Mailing Address - Fax:888-298-0519
Practice Address - Street 1:328 GLEN ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-4653
Practice Address - Country:US
Practice Address - Phone:843-834-2656
Practice Address - Fax:888-298-0519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
SC11521189305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No305R00000XManaged Care OrganizationsPreferred Provider OrganizationGroup - Single Specialty