Provider Demographics
NPI:1700043759
Name:IVANOVA, MASHA Y (PHD)
Entity Type:Individual
Prefix:DR
First Name:MASHA
Middle Name:Y
Last Name:IVANOVA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:Y
Other - Last Name:IVANOVA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1 SOUTH PROSPECT STREET
Mailing Address - Street 2:UHC ST JOSEPHS WING 3RD FLOOR
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401
Mailing Address - Country:US
Mailing Address - Phone:802-656-2796
Mailing Address - Fax:
Practice Address - Street 1:1 SOUTH PROSPECT STREET
Practice Address - Street 2:UHC ST JOSEPHS WING 3RD FLOOR
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401
Practice Address - Country:US
Practice Address - Phone:802-656-2796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT048-0000914103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent