Provider Demographics
NPI:1558804443
Name:IVANOVIC, MARIANA (PHD)
Entity Type:Individual
Prefix:
First Name:MARIANA
Middle Name:
Last Name:IVANOVIC
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2211 E NORTHERN LIGHTS BLVD
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4129
Mailing Address - Country:US
Mailing Address - Phone:907-279-8486
Mailing Address - Fax:907-677-5614
Practice Address - Street 1:2211 E NORTHERN LIGHTS BLVD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4129
Practice Address - Country:US
Practice Address - Phone:907-279-8486
Practice Address - Fax:907-677-5614
Is Sole Proprietor?:No
Enumeration Date:2016-11-23
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK116085103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical