Provider Demographics
NPI:1982043394
Name:INNOVATIVE THERAPY SERVICES, LLC
Entity Type:Organization
Organization Name:INNOVATIVE THERAPY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:814-240-1011
Mailing Address - Street 1:3939 W RIDGE RD
Mailing Address - Street 2:SUITE B-45
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-1879
Mailing Address - Country:US
Mailing Address - Phone:814-240-1011
Mailing Address - Fax:814-240-1048
Practice Address - Street 1:3939 W RIDGE RD
Practice Address - Street 2:SUITE B-45
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-1879
Practice Address - Country:US
Practice Address - Phone:814-240-1011
Practice Address - Fax:814-240-1048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-19
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC005212101YP2500X
PACW0160171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA319032Medicare PIN