Provider Demographics
NPI:1255607271
Name:INNOVATIVE CENTERED COUNSELING INC.
Entity type:Organization
Organization Name:INNOVATIVE CENTERED COUNSELING INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MOSES
Authorized Official - Middle Name:
Authorized Official - Last Name:CHISM
Authorized Official - Suffix:JR
Authorized Official - Credentials:LPC
Authorized Official - Phone:972-298-2020
Mailing Address - Street 1:1102 SANTA FE TRL
Mailing Address - Street 2:STE 3
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75137-3062
Mailing Address - Country:US
Mailing Address - Phone:972-298-2020
Mailing Address - Fax:972-298-2020
Practice Address - Street 1:1102 SANTA FE TRL
Practice Address - Street 2:STE 3
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75137-3062
Practice Address - Country:US
Practice Address - Phone:972-298-2020
Practice Address - Fax:972-298-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-23
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65923101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty