Provider Demographics
NPI:1669081188
Name:IVY, LISA FAYE
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:FAYE
Last Name:IVY
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 1:63 WALL ST APT 518
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10005-3025
Mailing Address - Country:US
Mailing Address - Phone:281-782-9411
Mailing Address - Fax:
Practice Address - Street 1:1560 MAYFLOWER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-5400
Practice Address - Country:US
Practice Address - Phone:718-948-1990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-30
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist