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General NPI Number Information
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NPI Number | 1851890628
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Entity Type | Organization
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Legal Business Name | IVY BEHAVIORAL GROUP INC
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Dates
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Enumeration Date | 02/07/2018
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Last Update Date | 05/06/2021
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Provider Practice Location Address
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Address Line | 2336 SE OCEAN BLVD # 167
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City | STUART
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State | FL
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Zip | 34996-3310
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Country | US
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Telephone | 772-208-0071
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Fax | 772-213-9558
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Provider Business Mailing Address
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Address Line | 1437 DENVER AVE # 157
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City | LOVELAND
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State | CO
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Zip | 80538-5226
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Country | US
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Telephone | 772-208-0071
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Fax |
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Authorized Official
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Title or Position | CEO/OWNER
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Name | EMILY GOSSER IVY
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Credential | BCBA
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Telephone | 772-208-0071
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 1-12-11892
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State |
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