Provider Demographics
NPI:1316134380
Name:IVY, ALAN (PHD)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:IVY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 RED ROCK DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73165-7377
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3625 W MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-4656
Practice Address - Country:US
Practice Address - Phone:405-579-7560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-03
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1051103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling