Provider Demographics
NPI:1710863436
Name:VAN RAVENSWAAY, IVAN A
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:A
Last Name:VAN RAVENSWAAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 E COTTONWOOD LN STE B4
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-2517
Mailing Address - Country:US
Mailing Address - Phone:928-975-4091
Mailing Address - Fax:
Practice Address - Street 1:2755 N CENTRE COURT DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85705-4281
Practice Address - Country:US
Practice Address - Phone:520-390-9243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-15
Last Update Date:2025-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-21190101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty