Provider Demographics
NPI:1255405320
Name:HRISTOV, IVAYLO (LCSW)
Entity type:Individual
Prefix:
First Name:IVAYLO
Middle Name:
Last Name:HRISTOV
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 1:10850 W PARK PL
Mailing Address - Street 2:STE 100
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53224-3636
Mailing Address - Country:US
Mailing Address - Phone:916-418-0828
Mailing Address - Fax:916-418-0838
Practice Address - Street 1:4465 N OAKLAND AVE UNIT 310
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:WI
Practice Address - Zip Code:53211-1662
Practice Address - Country:US
Practice Address - Phone:530-574-6855
Practice Address - Fax:414-755-7772
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW 171681041C0700X
WI7835-1231041C0700X
CALCSW276881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical