Provider Demographics
NPI:1932070729
Name:JOHNSON, IVY (BT)
Entity type:Individual
Prefix:
First Name:IVY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:BT
Other - Prefix:
Other - First Name:IVY
Other - Middle Name:
Other - Last Name:KYSAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:303 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OK
Mailing Address - Zip Code:74020-3421
Mailing Address - Country:US
Mailing Address - Phone:539-209-1209
Mailing Address - Fax:539-203-3672
Practice Address - Street 1:303 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OK
Practice Address - Zip Code:74020-3421
Practice Address - Country:US
Practice Address - Phone:539-209-1209
Practice Address - Fax:539-203-3672
Is Sole Proprietor?:No
Enumeration Date:2025-09-15
Last Update Date:2025-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician