Provider Demographics
NPI:1033306733
Name:CHONG, IVY (PHD)
Entity Type:Individual
Prefix:DR
First Name:IVY
Middle Name:
Last Name:CHONG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 W UNIVERSITY BLVD
Mailing Address - Street 2:SCOTT CENTER FOR AUTISM TREATMENT
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-6982
Mailing Address - Country:US
Mailing Address - Phone:321-674-8615
Mailing Address - Fax:321-674-8411
Practice Address - Street 1:150 W UNIVERSITY BLVD
Practice Address - Street 2:SCOTT CENTER FOR AUTISM TREATMENT
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-6982
Practice Address - Country:US
Practice Address - Phone:321-674-8615
Practice Address - Fax:321-674-8411
Is Sole Proprietor?:No
Enumeration Date:2007-09-27
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-04-1585103K00000X
MI6301012869103TC2200X
FL8214103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent