Provider Demographics
NPI:1538344304
Name:ENAGE, IVY B (PT)
Entity type:Individual
Prefix:MISS
First Name:IVY
Middle Name:B
Last Name:ENAGE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2209 WHITE ROCKS RD
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-4232
Mailing Address - Country:US
Mailing Address - Phone:732-485-1321
Mailing Address - Fax:
Practice Address - Street 1:2501 DOWNING ST SW
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-4517
Practice Address - Country:US
Practice Address - Phone:732-485-1321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-29
Last Update Date:2021-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01062800174400000X
NCP12386225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialist