Provider Demographics
NPI:1912294091
Name:IVY, MICHELLE D
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:D
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 1:4119 W HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60624-3549
Mailing Address - Country:US
Mailing Address - Phone:708-307-2191
Mailing Address - Fax:
Practice Address - Street 1:4119 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60624-3549
Practice Address - Country:US
Practice Address - Phone:708-307-2191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-08
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist