Provider Demographics
NPI:1942948112
Name:IVANCIC, COLE (LCSW)
Entity type:Individual
Prefix:
First Name:COLE
Middle Name:
Last Name:IVANCIC
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3709 N LOCUST GROVE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5924
Mailing Address - Country:US
Mailing Address - Phone:208-860-2598
Mailing Address - Fax:
Practice Address - Street 1:3709 N LOCUST GROVE RD STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-5924
Practice Address - Country:US
Practice Address - Phone:208-860-2598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-26
Last Update Date:2025-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID89110121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical