Provider Demographics
NPI:1881914380
Name:IVORY, LYDIA ANN (LPCI)
Entity type:Individual
Prefix:MRS
First Name:LYDIA
Middle Name:ANN
Last Name:IVORY
Suffix:
Gender:F
Credentials:LPCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6612 N RIVERSIDE DR
Mailing Address - Street 2:140
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-6663
Mailing Address - Country:US
Mailing Address - Phone:817-306-9770
Mailing Address - Fax:
Practice Address - Street 1:6612 N RIVERSIDE DR
Practice Address - Street 2:140
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-6663
Practice Address - Country:US
Practice Address - Phone:817-306-9770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-07
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66486101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional