Provider Demographics
NPI:1578392718
Name:IVY, TANYA D
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:D
Last Name:IVY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17620 SW 32ND ST
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33029-5605
Mailing Address - Country:US
Mailing Address - Phone:786-554-9283
Mailing Address - Fax:
Practice Address - Street 1:17620 SW 32ND ST
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33029-5605
Practice Address - Country:US
Practice Address - Phone:786-554-9283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-27
Last Update Date:2024-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health