Provider Demographics
NPI:1104062868
Name:IVY, TAMMI RENEE (MRC, LPC)
Entity type:Individual
Prefix:MRS
First Name:TAMMI
Middle Name:RENEE
Last Name:IVY
Suffix:
Gender:F
Credentials:MRC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 EDWARDS ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:AR
Mailing Address - Zip Code:72112-9074
Mailing Address - Country:US
Mailing Address - Phone:870-926-2840
Mailing Address - Fax:870-523-9301
Practice Address - Street 1:3358 SUITE D. S. 2ND STREET
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023
Practice Address - Country:US
Practice Address - Phone:501-286-6053
Practice Address - Fax:870-523-9301
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-31
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP0411049101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR169387795Medicaid