Provider Demographics
NPI:1104338763
Name:HORN, IVY RENEE
Entity type:Individual
Prefix:
First Name:IVY
Middle Name:RENEE
Last Name:HORN
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 1:21650 W 11 MILE RD STE 107
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-3715
Mailing Address - Country:US
Mailing Address - Phone:248-514-7254
Mailing Address - Fax:
Practice Address - Street 1:29623 NORTHWESTERN HWY STE 5
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1076
Practice Address - Country:US
Practice Address - Phone:248-514-7254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-03
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401001847101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional