Provider Demographics
NPI:1609569540
Name:STREET, IVY DIANE
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:DIANE
Last Name:STREET
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 1:1909 O CT SE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-6955
Mailing Address - Country:US
Mailing Address - Phone:760-223-3919
Mailing Address - Fax:
Practice Address - Street 1:8725 S 212TH ST
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98031-1921
Practice Address - Country:US
Practice Address - Phone:425-658-3016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-26
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician