Provider Demographics
NPI:1619360898
Name:HIVELY, JODIE (MSED, LMFTA)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:
Last Name:HIVELY
Suffix:
Gender:F
Credentials:MSED, LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3842 NEW VISION DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1708
Mailing Address - Country:US
Mailing Address - Phone:260-471-2300
Mailing Address - Fax:
Practice Address - Street 1:3842 NEW VISION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1708
Practice Address - Country:US
Practice Address - Phone:260-471-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-11
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN85000194A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health