Provider Demographics
NPI:1881225167
Name:INNOVATIVE STATE OF MIND LLC
Entity Type:Organization
Organization Name:INNOVATIVE STATE OF MIND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:M
Authorized Official - Last Name:HUFFINES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:240-486-0694
Mailing Address - Street 1:1147 S SALISBURY BLVD STE 8
Mailing Address - Street 2:#274
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-6865
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:116 BAPTIST ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-4911
Practice Address - Country:US
Practice Address - Phone:240-486-0694
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty