Provider Demographics
NPI:1851890628
Name:IVY BEHAVIORAL GROUP INC
Entity Type:Organization
Organization Name:IVY BEHAVIORAL GROUP INC
Other - Org Name:IVY BEHAVIORAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:GOSSER
Authorized Official - Last Name:IVY
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:772-208-0071
Mailing Address - Street 1:1437 DENVER AVE # 157
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-5226
Mailing Address - Country:US
Mailing Address - Phone:772-208-0071
Mailing Address - Fax:
Practice Address - Street 1:2336 SE OCEAN BLVD # 167
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34996-3310
Practice Address - Country:US
Practice Address - Phone:772-208-0071
Practice Address - Fax:772-213-9558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-07
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FL1-12-11892251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023921300Medicaid