Basic Information
| Provider Information | |||||||||
| NPI: | 1508519489 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IVYREHAB MICHIGAN, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1311 MAMARONECK AVE STE 140 | ||||||||
| Address2: | |||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106055224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142654582 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12319 HIGHLAND RD STE 301 | ||||||||
| Address2: | |||||||||
| City: | HARTLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483532946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109911211 | ||||||||
| FaxNumber: | 8109911656 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2022 | ||||||||
| LastUpdateDate: | 01/31/2022 | ||||||||
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| AuthorizedOfficialLastName: | CURATOLO | ||||||||
| AuthorizedOfficialFirstName: | GIACOMA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PAYER RELATIONS | ||||||||
| AuthorizedOfficialTelephone: | 9142654522 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.