Healthcare Provider Details

I. General information

NPI: 1851890628
Provider Name (Legal Business Name): IVY BEHAVIORAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2018
Last Update Date: 05/06/2021
Certification Date: 05/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2336 SE OCEAN BLVD # 167
STUART FL
34996-3310
US

IV. Provider business mailing address

1437 DENVER AVE # 157
LOVELAND CO
80538-5226
US

V. Phone/Fax

Practice location:
  • Phone: 772-208-0071
  • Fax: 772-213-9558
Mailing address:
  • Phone: 772-208-0071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1-12-11892
License Number StateFL

VIII. Authorized Official

Name: EMILY GOSSER IVY
Title or Position: CEO/OWNER
Credential: BCBA
Phone: 772-208-0071