Provider Demographics
NPI:1801844394
Name:IVEY, ROBERT G
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:G
Last Name:IVEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8209
Mailing Address - Country:US
Mailing Address - Phone:575-521-3025
Mailing Address - Fax:575-521-3565
Practice Address - Street 1:1130 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8209
Practice Address - Country:US
Practice Address - Phone:575-521-3025
Practice Address - Fax:575-521-3565
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2917231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMG9684Medicaid