Healthcare Provider Details

I. General information

NPI: 1013163187
Provider Name (Legal Business Name): ALAN VINCENT IVICIC LCSW-R
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2008
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 ROUTE 6
MAHOPAC NY
10541-3850
US

IV. Provider business mailing address

220 ROUTE 6
MAHOPAC NY
10541-3850
US

V. Phone/Fax

Practice location:
  • Phone: 917-336-4289
  • Fax:
Mailing address:
  • Phone: 917-336-4289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number079338
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: