Provider Demographics
NPI:1417546813
Name:IVEY, BETH
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:IVEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 JASPER CT
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-1658
Mailing Address - Country:US
Mailing Address - Phone:646-327-5910
Mailing Address - Fax:
Practice Address - Street 1:2288 BLUE WATER BLVD STE 440
Practice Address - Street 2:
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-3312
Practice Address - Country:US
Practice Address - Phone:410-674-7403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRO1833225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist