Provider Demographics
NPI:1164013876
Name:IVY, CHARLOTTE (LPC)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:IVY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9843 BLAINE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77086-2878
Mailing Address - Country:US
Mailing Address - Phone:337-257-9065
Mailing Address - Fax:888-511-5650
Practice Address - Street 1:1921 DULLES DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-2716
Practice Address - Country:US
Practice Address - Phone:337-223-9487
Practice Address - Fax:888-511-5650
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2021-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
12345678999966655525OtherINTERN NUMBER
LAPLC6505OtherLICENSE #