Provider Demographics
NPI:1326580994
Name:NGUYEN, IVY TRUC (LMSW)
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:TRUC
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2092 N DEVLIN AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-7327
Mailing Address - Country:US
Mailing Address - Phone:208-230-3185
Mailing Address - Fax:
Practice Address - Street 1:5999 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-5059
Practice Address - Country:US
Practice Address - Phone:208-853-5095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-14
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-35671104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker