Provider Demographics
NPI:1265802698
Name:IVY, MICHAEL B (LCSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:B
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 1:50 PINE COUNTRY DR
Mailing Address - Street 2:
Mailing Address - City:BUXTON
Mailing Address - State:ME
Mailing Address - Zip Code:04093-6447
Mailing Address - Country:US
Mailing Address - Phone:207-807-9110
Mailing Address - Fax:207-560-9860
Practice Address - Street 1:110 MAIN ST STE 1508
Practice Address - Street 2:
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072-3517
Practice Address - Country:US
Practice Address - Phone:207-807-9110
Practice Address - Fax:207-560-9860
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-28
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC168661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical