Provider Demographics
NPI:1578578092
Name:INNOVATIVE BEHAVIORALS SERVICES, INC.
Entity Type:Organization
Organization Name:INNOVATIVE BEHAVIORALS SERVICES, INC.
Other - Org Name:IBS, INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:COO
Authorized Official - Prefix:DR
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCGILL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:601-952-0894
Mailing Address - Street 1:357 TOWNE CENTER BLVD
Mailing Address - Street 2:SUITE # 100
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-4837
Mailing Address - Country:US
Mailing Address - Phone:601-952-0894
Mailing Address - Fax:601-952-0836
Practice Address - Street 1:357 TOWNE CENTER BLVD
Practice Address - Street 2:SUITE # 100
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4837
Practice Address - Country:US
Practice Address - Phone:601-952-0894
Practice Address - Fax:601-952-0836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSLH0186101YM0800X
MS34561103TC0700X
MSC60341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS587443922OtherBLUE CROSS BLUE SHIELD
MS09015770Medicaid