Provider Demographics
NPI:1801238431
Name:MICIC, IVANA
Entity type:Individual
Prefix:
First Name:IVANA
Middle Name:
Last Name:MICIC
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 1:166 E COATSVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-1925
Mailing Address - Country:US
Mailing Address - Phone:801-615-4246
Mailing Address - Fax:
Practice Address - Street 1:150 E 700 S
Practice Address - Street 2:PROJECT REALITY
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-3806
Practice Address - Country:US
Practice Address - Phone:801-364-8080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-24
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9424937-3501101YM0800X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical