Provider Demographics
NPI:1336851567
Name:MITIC, IVANA
Entity Type:Individual
Prefix:
First Name:IVANA
Middle Name:
Last Name:MITIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 BELLEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-1308
Mailing Address - Country:US
Mailing Address - Phone:973-450-3100
Mailing Address - Fax:
Practice Address - Street 1:570 BELLEVILLE AVE
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-1308
Practice Address - Country:US
Practice Address - Phone:973-450-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00623000101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health