Healthcare Provider Details

I. General information

NPI: 1386572477
Provider Name (Legal Business Name): IVY MACNICOL LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 BRIDGE ST
EAST JORDAN MI
49727-9421
US

IV. Provider business mailing address

601 BRIDGE ST
EAST JORDAN MI
49727-9421
US

V. Phone/Fax

Practice location:
  • Phone: 231-536-2206
  • Fax: 231-536-7150
Mailing address:
  • Phone: 231-536-2206
  • Fax: 231-536-7150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851121874
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: