Individual
IVY HARRIS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
4613 MARTHAS WAY, GROVETOWN, GA 30813-2205
(732) 962-5450
Mailing address
4613 MARTHA'S WAY, GROVETOWN, GA 30813
(732) 962-5450
Taxonomy
Speciality
Code
Description
License number
State
320600000X
Intellectual and/or Developmental Disabilities Residential Treatment Facility
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000606317B
—
GA
Enumeration date
06/10/2014
Last updated
06/10/2014
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