Provider Demographics
NPI:1669669784
Name:IVAN, ANCA MIRELA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ANCA
Middle Name:MIRELA
Last Name:IVAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 BLANKENSHIP RD
Mailing Address - Street 2:# 200
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-4172
Mailing Address - Country:US
Mailing Address - Phone:503-650-2240
Mailing Address - Fax:503-650-2248
Practice Address - Street 1:1800 BLANKENSHIP RD
Practice Address - Street 2:# 200
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-4172
Practice Address - Country:US
Practice Address - Phone:503-650-2240
Practice Address - Fax:503-650-2248
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-02
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 19910103TC0700X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1932OtherLICENSE #