Provider Demographics
NPI:1427593128
Name:LONG, IVORY MAE CHAVEZ
Entity Type:Individual
Prefix:
First Name:IVORY MAE
Middle Name:CHAVEZ
Last Name:LONG
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 1:1540 NELSON PL
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93033-6613
Mailing Address - Country:US
Mailing Address - Phone:805-824-1887
Mailing Address - Fax:
Practice Address - Street 1:1540 NELSON PL
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93033-6613
Practice Address - Country:US
Practice Address - Phone:805-824-1887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-04
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77840104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker