Provider Demographics
NPI:1013373273
Name:IVIE, MINDY LU
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:LU
Last Name:IVIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1282 RT 113 #126
Mailing Address - Street 2:
Mailing Address - City:BLOOMING GLEN
Mailing Address - State:PA
Mailing Address - Zip Code:18911
Mailing Address - Country:US
Mailing Address - Phone:267-424-3240
Mailing Address - Fax:
Practice Address - Street 1:1282 RT 113
Practice Address - Street 2:
Practice Address - City:BLOOMING GLEN
Practice Address - State:PA
Practice Address - Zip Code:18911
Practice Address - Country:US
Practice Address - Phone:267-424-3240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-04
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG007317225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist