Provider Demographics
NPI:1952790099
Name:IVEY, LORRAINE MICHELLE
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:MICHELLE
Last Name:IVEY
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 1:115 N 200 E
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84780-1642
Mailing Address - Country:US
Mailing Address - Phone:435-669-8981
Mailing Address - Fax:
Practice Address - Street 1:115 N 200 E
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:UT
Practice Address - Zip Code:84780-1642
Practice Address - Country:US
Practice Address - Phone:435-669-8981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT901207545-04OtherALTIUS