Healthcare Provider Details

I. General information

NPI: 1922513738
Provider Name (Legal Business Name): IVY COUNSELING & WELLNESS SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2017
Last Update Date: 12/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

326 SAINT MATTHIAS DR
CARENCRO LA
70520-5576
US

IV. Provider business mailing address

326 SAINT MATTHIAS DR
CARENCRO LA
70520-5576
US

V. Phone/Fax

Practice location:
  • Phone: 310-429-5025
  • Fax:
Mailing address:
  • Phone: 310-429-5025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. IVY DESIRAE BENNETT SIAS
Title or Position: OWNER
Credential: LPC
Phone: 310-429-5025