Provider Demographics
NPI:1922624816
Name:NALLEY, IVY L (LCSW, CAADC)
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:L
Last Name:NALLEY
Suffix:
Gender:F
Credentials:LCSW, CAADC
Other - Prefix:
Other - First Name:IVY
Other - Middle Name:NALLEY
Other - Last Name:ROSHTO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2505 BELLEVUE AVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-4609
Mailing Address - Country:US
Mailing Address - Phone:706-799-0296
Mailing Address - Fax:
Practice Address - Street 1:3150 PERIMETER PKWY STE 110
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-5797
Practice Address - Country:US
Practice Address - Phone:706-339-2854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-17
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAC0281101YA0400X
GACSW0071841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)