Provider Demographics
NPI:1073837670
Name:IVY, LISA
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:IVY
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:PO BOX 2049
Mailing Address - Street 2:
Mailing Address - City:CHANNELVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:77530-8049
Mailing Address - Country:US
Mailing Address - Phone:281-282-7027
Mailing Address - Fax:281-862-9148
Practice Address - Street 1:450 EL DORADO BLVD
Practice Address - Street 2:# 720
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-2317
Practice Address - Country:US
Practice Address - Phone:281-282-7027
Practice Address - Fax:281-862-9148
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-25
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor