Provider Demographics
NPI:1528658416
Name:IVY HEALTH AND PSYCHOLOGICAL SERVICES LLC
Entity type:Organization
Organization Name:IVY HEALTH AND PSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LATOYA
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC, PMHNP-BC
Authorized Official - Phone:757-202-6461
Mailing Address - Street 1:PO BOX 12731
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23541-0731
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1577 WILROY RD STE 102
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-2433
Practice Address - Country:US
Practice Address - Phone:757-202-6461
Practice Address - Fax:757-257-9173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-25
Last Update Date:2022-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty