Healthcare Provider Details

I. General information

NPI: 1295213171
Provider Name (Legal Business Name): IVY PSYCHOTHERAPIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2018
Last Update Date: 08/02/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 PERSHING ST SUITE 1
CRAIG CO
81625-3053
US

IV. Provider business mailing address

2340 W 1620 N CIRCLE
ST GEORGE UT
84770-5313
US

V. Phone/Fax

Practice location:
  • Phone: 917-730-7789
  • Fax: 970-367-1499
Mailing address:
  • Phone: 917-730-7789
  • Fax: 970-367-1499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9923637
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier52720586
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name: MRS. ELISA H ALVIM-TOLD
Title or Position: OWNER
Credential: LCSW
Phone: 917-730-7789