Provider Demographics
NPI:1669719803
Name:INNOVATIVE BEHAVIORAL HEALTH
Entity type:Organization
Organization Name:INNOVATIVE BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:JOHANN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:317-902-2205
Mailing Address - Street 1:5548 PAINTED MAPLE CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-9630
Mailing Address - Country:US
Mailing Address - Phone:317-902-2205
Mailing Address - Fax:
Practice Address - Street 1:7855 S EMERSON AVE
Practice Address - Street 2:SUITE H
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8668
Practice Address - Country:US
Practice Address - Phone:317-902-2205
Practice Address - Fax:317-300-0422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-08
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34006255A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty