Provider Demographics
NPI:1679354971
Name:INNOVATIVE TRAUMA THERAPY, PLLC
Entity Type:Organization
Organization Name:INNOVATIVE TRAUMA THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOTHERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:COOK
Authorized Official - Last Name:ROVIRA
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:903-363-6516
Mailing Address - Street 1:220 N PARK BLVD STE 112
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-6900
Mailing Address - Country:US
Mailing Address - Phone:817-330-9730
Mailing Address - Fax:
Practice Address - Street 1:220 N PARK BLVD STE 112
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-6900
Practice Address - Country:US
Practice Address - Phone:817-330-9730
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1891042255Medicaid
TX1568739563Medicaid