MEDICARE: IVA MAYLENE HALLSTED CLEARWATER LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	1803	FL
2	1041C0700X	Clinical Social Worker	SW4959	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2027492	OTHER	FL	CIGNA
2	238116	OTHER	FL	MHN MANAGED CARE ORG
3	28762	OTHER	FL	BCBS BLUE CROSS BLUE SHIE
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952419749
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IVA MAYLENE HALLSTED CLEARWATER LCSW

Provider Business Mailing Address
First Line	:	4500 W MIDWAY RD
Second Line	:	NEW HORIZONS OF THE TREASURE COAST INC
City	:	FT PIERCE
State	:	FL
Zip	:	34981
Country	:	US
Telephone Number	:	772-672-5600
Fax Number	:	772-468-4033

Provider Business Practice Location Address
First Line	:	4500 W MIDWAY RD
Second Line	:	NEW HORIZONS OF THE TREASURE COAST INC
City	:	FT PIERCE
State	:	FL
Zip	:	34981
Country	:	US
Telephone Number	:	772-672-5600
Fax Number	:	772-468-4033

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	09/25/2013

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