Provider Demographics
NPI:1689882995
Name:IVY, MATTIE (SLP)
Entity Type:Individual
Prefix:MS
First Name:MATTIE
Middle Name:
Last Name:IVY
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 PARK ST
Mailing Address - Street 2:
Mailing Address - City:FORREST CITY
Mailing Address - State:AR
Mailing Address - Zip Code:72335-4823
Mailing Address - Country:US
Mailing Address - Phone:870-633-4366
Mailing Address - Fax:870-792-7371
Practice Address - Street 1:724 PARK ST
Practice Address - Street 2:
Practice Address - City:FORREST CITY
Practice Address - State:AR
Practice Address - Zip Code:72335-4823
Practice Address - Country:US
Practice Address - Phone:870-633-4366
Practice Address - Fax:870-792-7371
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP 822235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR127746721Medicaid