Provider Demographics
NPI:1023568755
Name:UNIQUE AND INNOVATIVE SOLUTIONS LLC
Entity type:Organization
Organization Name:UNIQUE AND INNOVATIVE SOLUTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TABITHA
Authorized Official - Middle Name:DELAINA
Authorized Official - Last Name:BALL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:607-795-1235
Mailing Address - Street 1:3645 MARKETPLACE BLVD
Mailing Address - Street 2:SUITE 130-669
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-5747
Mailing Address - Country:US
Mailing Address - Phone:404-217-8657
Mailing Address - Fax:
Practice Address - Street 1:3645 MARKETPLACE BLVD STE 130-669
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-5747
Practice Address - Country:US
Practice Address - Phone:404-217-8657
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-05
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 103T00000X, 103TB0200X
GAPSY003839103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003183738CMedicaid