Provider Demographics
NPI:1417428665
Name:IVY GLENN WELLNESS
Entity Type:Organization
Organization Name:IVY GLENN WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BACHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:858-663-0651
Mailing Address - Street 1:30011 IVY GLENN DR STE 216
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-5018
Mailing Address - Country:US
Mailing Address - Phone:949-484-9161
Mailing Address - Fax:
Practice Address - Street 1:30011 IVY GLENN DR STE 216
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-5018
Practice Address - Country:US
Practice Address - Phone:949-484-9161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty