Provider Demographics
NPI:1710188396
Name:IVY REIGN SUPPORT SERVICES
Entity Type:Organization
Organization Name:IVY REIGN SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:TOLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:MASTER OF SCIENCE
Authorized Official - Phone:254-799-3200
Mailing Address - Street 1:4305 GRAM LN
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76705-2661
Mailing Address - Country:US
Mailing Address - Phone:254-799-3200
Mailing Address - Fax:254-799-3204
Practice Address - Street 1:4305 GRAM LN
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76705-2661
Practice Address - Country:US
Practice Address - Phone:254-799-3200
Practice Address - Fax:254-799-3204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX001007980251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services