Provider Demographics
NPI:1417731290
Name:IVANCICTS, ABIGAIL KATHLEEN (LCSW)
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:KATHLEEN
Last Name:IVANCICTS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:REX
Other - Middle Name:BLAIR
Other - Last Name:WYATT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 19639
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9639
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-2101
Practice Address - Street 1:520 N 4TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5238
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-757-8161
Is Sole Proprietor?:No
Enumeration Date:2023-08-22
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0258231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical