Provider Demographics
NPI:1376748939
Name:IVEY, CHARLOTTE D (LISW-S, PHD)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:D
Last Name:IVEY
Suffix:
Gender:F
Credentials:LISW-S, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6278 N FEDERAL HIGHWAY
Mailing Address - Street 2:#703
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-1916
Mailing Address - Country:US
Mailing Address - Phone:216-491-1735
Mailing Address - Fax:
Practice Address - Street 1:6278 N FEDERAL HIGHWAY
Practice Address - Street 2:#703
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-1916
Practice Address - Country:US
Practice Address - Phone:216-491-1735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-15
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW211971041C0700X
OHI 48401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0264586Medicaid