Provider Demographics
NPI:1790103828
Name:INNOVATION AVENUE CONSULTING LLC
Entity Type:Organization
Organization Name:INNOVATION AVENUE CONSULTING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LEAD COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:KENYOTA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:DOKES
Authorized Official - Suffix:
Authorized Official - Credentials:MA LPC
Authorized Official - Phone:314-502-9682
Mailing Address - Street 1:PO BOX 1721
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-0050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:606 DAVIDSON CT
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-2472
Practice Address - Country:US
Practice Address - Phone:314-246-9249
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-05
Last Update Date:2014-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012005837101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty