Provider Demographics
NPI:1891820841
Name:INNOVATIVE COUNSELING & CONSULTING
Entity Type:Organization
Organization Name:INNOVATIVE COUNSELING & CONSULTING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:901-276-0220
Mailing Address - Street 1:1455 POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-2934
Mailing Address - Country:US
Mailing Address - Phone:901-276-0220
Mailing Address - Fax:901-276-0225
Practice Address - Street 1:1455 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-2934
Practice Address - Country:US
Practice Address - Phone:901-276-0220
Practice Address - Fax:901-276-0225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No251S00000XAgenciesCommunity/Behavioral Health
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3289013Medicare PIN