Provider Demographics
NPI:1588317945
Name:IVORY, REBECCA JEAN
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:JEAN
Last Name:IVORY
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 1:11075 S STATE ST STE 13
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-5193
Mailing Address - Country:US
Mailing Address - Phone:801-694-8382
Mailing Address - Fax:
Practice Address - Street 1:11075 S STATE ST STE 13
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-5193
Practice Address - Country:US
Practice Address - Phone:801-694-8382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-26
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist