Provider Demographics
NPI:1477633675
Name:IVANOV, MONIQUE (MSW)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:IVANOV
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6809 RIVER HILLS DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-8339
Mailing Address - Country:US
Mailing Address - Phone:336-664-6988
Mailing Address - Fax:
Practice Address - Street 1:6809 RIVER HILLS DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-8339
Practice Address - Country:US
Practice Address - Phone:336-664-6988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0000841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical