Provider Demographics
NPI:1265632442
Name:EGLIVITCH, MINDY (LCSW)
Entity type:Individual
Prefix:MS
First Name:MINDY
Middle Name:
Last Name:EGLIVITCH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16772 W BELL RD STE 110-186
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-9702
Mailing Address - Country:US
Mailing Address - Phone:781-797-7685
Mailing Address - Fax:
Practice Address - Street 1:16772 W BELL RD STE 110-186
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-9702
Practice Address - Country:US
Practice Address - Phone:781-797-7685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-196731041C0700X
NCC0057271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical