Provider Demographics
NPI:1942948112
Name:IVANCIC, COLE (LMSW)
Entity Type:Individual
Prefix:
First Name:COLE
Middle Name:
Last Name:IVANCIC
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3451 N ARROWWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-6079
Mailing Address - Country:US
Mailing Address - Phone:208-860-2598
Mailing Address - Fax:
Practice Address - Street 1:2950 E MAGIC VIEW DR STE 192
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6246
Practice Address - Country:US
Practice Address - Phone:208-600-2184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-26
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker