Provider Demographics
NPI:1134447386
Name:IVY, CHUCK (LCSW)
Entity type:Individual
Prefix:
First Name:CHUCK
Middle Name:
Last Name:IVY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-2146
Mailing Address - Country:US
Mailing Address - Phone:575-208-2918
Mailing Address - Fax:575-208-2918
Practice Address - Street 1:1407 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-2146
Practice Address - Country:US
Practice Address - Phone:575-208-2918
Practice Address - Fax:575-208-2918
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-12
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-100131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical