Provider Demographics
NPI:1891067377
Name:INNOVATIVE CAREER CENTER LLC
Entity Type:Organization
Organization Name:INNOVATIVE CAREER CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:NELLY
Authorized Official - Last Name:LAVERGNE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:917-445-6323
Mailing Address - Street 1:268 EDGEMONT TER
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-3404
Mailing Address - Country:US
Mailing Address - Phone:917-445-6323
Mailing Address - Fax:212-313-9439
Practice Address - Street 1:116 W 23RD ST
Practice Address - Street 2:#206, 5TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-2599
Practice Address - Country:US
Practice Address - Phone:917-445-6323
Practice Address - Fax:212-313-9439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-31
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000351-1103TM1800X
NJ37RT00288300103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Single Specialty
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitationGroup - Single Specialty