Provider Demographics
NPI:1679296420
Name:IVY, MADISON LEIGH (LMSW)
Entity Type:Individual
Prefix:MS
First Name:MADISON
Middle Name:LEIGH
Last Name:IVY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2808 NW 17TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73107-3931
Mailing Address - Country:US
Mailing Address - Phone:806-640-4779
Mailing Address - Fax:
Practice Address - Street 1:2808 NW 17TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73107-3931
Practice Address - Country:US
Practice Address - Phone:806-640-4779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8217104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker