Provider Demographics
NPI:1982006904
Name:INNOVATIVE THERAPY OF GEORGIA
Entity Type:Organization
Organization Name:INNOVATIVE THERAPY OF GEORGIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:866-377-5454
Mailing Address - Street 1:2470 WINDY HILL RD SE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-8613
Mailing Address - Country:US
Mailing Address - Phone:866-377-5454
Mailing Address - Fax:
Practice Address - Street 1:2470 WINDY HILL RD SE
Practice Address - Street 2:SUITE 300
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8613
Practice Address - Country:US
Practice Address - Phone:866-377-5454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-22
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007825103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty