Provider Demographics
NPI:1740365006
Name:FREEMAN, IVY FLORENCE (MA)
Entity type:Individual
Prefix:MS
First Name:IVY
Middle Name:FLORENCE
Last Name:FREEMAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 EASTERLY AVENUE
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701
Mailing Address - Country:US
Mailing Address - Phone:802-773-1116
Mailing Address - Fax:802-773-1116
Practice Address - Street 1:10 EASTERLY AVENUE
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701
Practice Address - Country:US
Practice Address - Phone:802-773-1116
Practice Address - Fax:802-773-1116
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0680000052101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT5660OtherBLUE CROSS BLUE SHIELD
VT1006859Medicaid