Provider Demographics
NPI:1689653743
Name:MALLISHAM, IVY J (PSYD)
Entity Type:Individual
Prefix:DR
First Name:IVY
Middle Name:J
Last Name:MALLISHAM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5041 WARM SPRINGS RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-6938
Mailing Address - Country:US
Mailing Address - Phone:706-569-9199
Mailing Address - Fax:706-569-8990
Practice Address - Street 1:5041 WARM SPRINGS RD
Practice Address - Street 2:SUITE B
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-6938
Practice Address - Country:US
Practice Address - Phone:706-569-9199
Practice Address - Fax:706-569-8990
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001132103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
68BBCLRMedicare ID - Type UnspecifiedCLINICAL PSYCHOLOGIST