Provider Demographics
NPI:1265798458
Name:HECK, IVY AUTUMN (MA)
Entity type:Individual
Prefix:MRS
First Name:IVY
Middle Name:AUTUMN
Last Name:HECK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1848 S ELENA AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-5710
Mailing Address - Country:US
Mailing Address - Phone:424-254-4200
Mailing Address - Fax:310-540-4580
Practice Address - Street 1:1848 S ELENA AVE STE 105
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-5710
Practice Address - Country:US
Practice Address - Phone:424-254-4200
Practice Address - Fax:310-540-4580
Is Sole Proprietor?:No
Enumeration Date:2012-04-02
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52515106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist