Provider Demographics
NPI:1164818217
Name:INNOVATION COUNSELING CENTER
Entity type:Organization
Organization Name:INNOVATION COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:MALONE
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:904-719-1043
Mailing Address - Street 1:9951 ATLANTIC BLVD
Mailing Address - Street 2:442
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-6584
Mailing Address - Country:US
Mailing Address - Phone:904-327-4261
Mailing Address - Fax:
Practice Address - Street 1:9951 ATLANTIC BLVD
Practice Address - Street 2:442
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-6584
Practice Address - Country:US
Practice Address - Phone:904-274-6255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-15
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH13087101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty