Basic Information
| Provider Information | |||||||||
| NPI: | 1205207800 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INNOVATION BEHAVIOR SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 39 BANGOR ST | ||||||||
| Address2: | |||||||||
| City: | HOULTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047301711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3022443404 | ||||||||
| FaxNumber: | 8555962438 | ||||||||
| Practice Location | |||||||||
| Address1: | 1474 E LEBANON RD | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199015833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3022443404 | ||||||||
| FaxNumber: | 8555962438 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2015 | ||||||||
| LastUpdateDate: | 04/30/2021 | ||||||||
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| AuthorizedOfficialLastName: | FOSS | ||||||||
| AuthorizedOfficialFirstName: | MAUREEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO/CLINICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3022443404 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | BCBA | ||||||||
| NPICertificationDate: | 04/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 251S00000X | 2015606572 | DE | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 12672941 | 01 | CAQH | OTHER | 1639596174 | 01 | NPI | OTHER | 1295235448 | 01 | NPI | OTHER | 14217958 | 01 | CAQH | OTHER | 14002656 | 01 | CAQH | OTHER | 136117681 | 01 | CAQH | OTHER | 1144653981 | 01 | NPI | OTHER | 1962937540 | 01 | NPI | OTHER |