Provider Demographics
NPI:1952419749
Name:CLEARWATER, IVA MAYLENE HALLSTED (LCSW)
Entity Type:Individual
Prefix:
First Name:IVA
Middle Name:MAYLENE HALLSTED
Last Name:CLEARWATER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 W MIDWAY RD
Mailing Address - Street 2:NEW HORIZONS OF THE TREASURE COAST INC
Mailing Address - City:FT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34981
Mailing Address - Country:US
Mailing Address - Phone:772-672-5600
Mailing Address - Fax:772-468-4033
Practice Address - Street 1:4500 W MIDWAY RD
Practice Address - Street 2:NEW HORIZONS OF THE TREASURE COAST INC
Practice Address - City:FT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34981
Practice Address - Country:US
Practice Address - Phone:772-672-5600
Practice Address - Fax:772-468-4033
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1803101YA0400X
FLSW49591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2027492OtherCIGNA
FL238116OtherMHN MANAGED CARE ORG
FL28762OtherBCBS BLUE CROSS BLUE SHIE
FL763665200Medicaid
FLZ8762YMedicare PIN