Provider Demographics
NPI:1548021447
Name:IVEY, THOMAS W
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:W
Last Name:IVEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4250 N MARINE DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613
Mailing Address - Country:US
Mailing Address - Phone:773-742-6684
Mailing Address - Fax:
Practice Address - Street 1:4250 N MARINE DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613
Practice Address - Country:US
Practice Address - Phone:773-742-6684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1501072391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical