Provider Demographics
NPI:1225668668
Name:PHOENIX, IVY MARE (CMHC)
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:MARE
Last Name:PHOENIX
Suffix:
Gender:F
Credentials:CMHC
Other - Prefix:
Other - First Name:ETTA
Other - Middle Name:IVYN
Other - Last Name:CHAVEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1447 N 1200 W
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-2449
Mailing Address - Country:US
Mailing Address - Phone:801-655-5450
Mailing Address - Fax:
Practice Address - Street 1:5691 S REDWOOD RD
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84123-5420
Practice Address - Country:US
Practice Address - Phone:801-655-5450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-24
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
UT11772649-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor