Provider Demographics
NPI:1114791829
Name:IVANKOVICH, LAUREN MAE
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:MAE
Last Name:IVANKOVICH
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 1:1990 WOODBURY CT
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-6240
Mailing Address - Country:US
Mailing Address - Phone:925-876-9016
Mailing Address - Fax:
Practice Address - Street 1:139 HUGO ST APT 3
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94122-2760
Practice Address - Country:US
Practice Address - Phone:650-797-2327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician