Provider Demographics
NPI:1306592894
Name:INNOVATIVE BEHAVIORAL CONCEPTS LLC
Entity type:Organization
Organization Name:INNOVATIVE BEHAVIORAL CONCEPTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELRITA
Authorized Official - Middle Name:
Authorized Official - Last Name:GODBOLD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:856-258-7464
Mailing Address - Street 1:104 CENTRE BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4130
Mailing Address - Country:US
Mailing Address - Phone:856-258-7464
Mailing Address - Fax:
Practice Address - Street 1:104 CENTRE BLVD STE A
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-4130
Practice Address - Country:US
Practice Address - Phone:856-258-7464
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-23
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health