Provider Demographics
NPI:1871154781
Name:IVY, CAROLINE ELISE
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:ELISE
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 1:290 S ALMA SCHOOL RD STE 1
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-7633
Mailing Address - Country:US
Mailing Address - Phone:480-812-2110
Mailing Address - Fax:
Practice Address - Street 1:290 S ALMA SCHOOL RD STE 1
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-7633
Practice Address - Country:US
Practice Address - Phone:480-812-2110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-23
Last Update Date:2019-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician