Provider Demographics
NPI:1144620089
Name:FIROUZTALE, IVY
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:
Last Name:FIROUZTALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:IVY
Other - Middle Name:
Other - Last Name:CLOSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:2 PUDDING LN
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-6118
Mailing Address - Country:US
Mailing Address - Phone:631-432-8424
Mailing Address - Fax:
Practice Address - Street 1:2 PUDDING LN
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-6118
Practice Address - Country:US
Practice Address - Phone:631-432-8424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-28
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY078295-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical