Provider Demographics
NPI:1225738859
Name:IVY, HEATHER ANN (SUDP III)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:ANN
Last Name:IVY
Suffix:
Gender:F
Credentials:SUDP III
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:ANN
Other - Last Name:SAMPLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SUDP-T
Mailing Address - Street 1:9650 15TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98106-2576
Mailing Address - Country:US
Mailing Address - Phone:206-965-1055
Mailing Address - Fax:206-965-1032
Practice Address - Street 1:1415 CENTER ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-8210
Practice Address - Country:US
Practice Address - Phone:253-280-9860
Practice Address - Fax:253-280-9870
Is Sole Proprietor?:No
Enumeration Date:2023-03-02
Last Update Date:2025-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP61678744101YA0400X
WACO61296221390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program