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General NPI Number Information
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NPI Number | 1487467957
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Entity Type | Individual
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Provider Name | MIA IVANCOVICH
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Gender | Female
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Dates
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Enumeration Date | 01/29/2025
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Last Update Date | 01/29/2025
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Provider Practice Location Address
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Address Line | 452 SUFFOLK AVE
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City | BRENTWOOD
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State | NY
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Zip | 11717-4214
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Country | US
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Telephone | 631-436-6065
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Fax |
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Provider Business Mailing Address
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Address Line | 67 MILLAY LN
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City | BAY SHORE
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State | NY
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Zip | 11706-4329
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Registered Nurse
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License Number | 813227-01
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 813227-01
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License Number State | NY
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