Provider Demographics
NPI:1417288044
Name:MACMAHON, IVY SMITH (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:IVY
Middle Name:SMITH
Last Name:MACMAHON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:852 TUCKER ROAD
Mailing Address - Street 2:
Mailing Address - City:DARTMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02747
Mailing Address - Country:US
Mailing Address - Phone:508-984-7273
Mailing Address - Fax:
Practice Address - Street 1:852 TUCKER RD
Practice Address - Street 2:
Practice Address - City:DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-3531
Practice Address - Country:US
Practice Address - Phone:508-984-7273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1062601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical