Healthcare Provider Details

I. General information

NPI: 1437071669
Provider Name (Legal Business Name): DAIJA IVY M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633 W 5TH ST OFC 2876B
LOS ANGELES CA
90071-2005
US

IV. Provider business mailing address

156 RICKMAN RD
PONTOTOC MS
38863-5416
US

V. Phone/Fax

Practice location:
  • Phone: 512-377-6318
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberS-5501
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202012645
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: