Provider Demographics
NPI:1164509303
Name:IVANCIC, ROBERT MARK (LPC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:MARK
Last Name:IVANCIC
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:14114 DALLAS PKWY
Mailing Address - Street 2:SUITE 260
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-4325
Mailing Address - Country:US
Mailing Address - Phone:214-207-6307
Mailing Address - Fax:972-774-0544
Practice Address - Street 1:14114 DALLAS PKWY
Practice Address - Street 2:SUITE 260
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75254-4325
Practice Address - Country:US
Practice Address - Phone:214-207-6307
Practice Address - Fax:972-774-0544
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12989101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional