Provider Demographics
NPI:1912495839
Name:INNOVATIVE THERAPEUTIC SERVICES
Entity Type:Organization
Organization Name:INNOVATIVE THERAPEUTIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GWYNETTH
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DBH, LCSW
Authorized Official - Phone:602-320-7925
Mailing Address - Street 1:15600 N BLACK CANYON HWY # C103
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-4055
Mailing Address - Country:US
Mailing Address - Phone:602-320-7925
Mailing Address - Fax:877-958-9033
Practice Address - Street 1:15600 N BLACK CANYON HWY STE C103
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-4055
Practice Address - Country:US
Practice Address - Phone:602-320-7925
Practice Address - Fax:877-958-9033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-26
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty