Provider Demographics
NPI:1447496757
Name:FLEISHMAN, IVAN (PSYD)
Entity type:Individual
Prefix:MR
First Name:IVAN
Middle Name:
Last Name:FLEISHMAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 W NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-5425
Mailing Address - Country:US
Mailing Address - Phone:386-736-8337
Mailing Address - Fax:386-736-8336
Practice Address - Street 1:339 W NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-5425
Practice Address - Country:US
Practice Address - Phone:386-736-8337
Practice Address - Fax:386-736-8336
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-17
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 3327103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75796OtherBLUE CROSS BLUE SHIELD OF FLORIDA