Provider Demographics
NPI:1407886054
Name:KAUFMAN, IVAN D (LCSW, MMT)
Entity Type:Individual
Prefix:MR
First Name:IVAN
Middle Name:D
Last Name:KAUFMAN
Suffix:
Gender:M
Credentials:LCSW, MMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7435 LA BOLSA DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-4248
Mailing Address - Country:US
Mailing Address - Phone:214-359-6072
Mailing Address - Fax:
Practice Address - Street 1:7435 LA BOLSA DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-4248
Practice Address - Country:US
Practice Address - Phone:214-359-6072
Practice Address - Fax:214-359-6072
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX260641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1590812-01Medicaid