MEDICARE: RICHARD SCOTT IVEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	25-492590	AL

General Provider Information

NPI Number	:	1366304073
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD SCOTT IVEY

Provider Business Mailing Address
First Line	:	194 GOLF VIEW DR
Second Line	:
City	:	DOTHAN
State	:	AL
Zip	:	36301-6813
Country	:	US
Telephone Number	:	334-618-3302
Fax Number	:

Provider Business Practice Location Address
First Line	:	112 ADRIS PL
Second Line	:
City	:	DOTHAN
State	:	AL
Zip	:	36303-1997
Country	:	US
Telephone Number	:	334-618-3302
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2025
Last Update Date	:	12/01/2025

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