Provider Demographics
NPI:1912265125
Name:CHILDREN'S INNOVATIVE THERAPY GROUP, LLC
Entity Type:Organization
Organization Name:CHILDREN'S INNOVATIVE THERAPY GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:301-652-2220
Mailing Address - Street 1:5109 BATTERY LN
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814-2413
Mailing Address - Country:US
Mailing Address - Phone:301-652-2220
Mailing Address - Fax:
Practice Address - Street 1:5109 BATTERY LN
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-2413
Practice Address - Country:US
Practice Address - Phone:301-652-2220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD0607261QA3000X, 261QD1600X, 261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QA3000XAmbulatory Health Care FacilitiesClinic/CenterAugmentative Communication
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities