Provider Demographics
NPI:1487870275
Name:IVATURY, BHANUMATHI (PHD LCSW)
Entity type:Individual
Prefix:DR
First Name:BHANUMATHI
Middle Name:
Last Name:IVATURY
Suffix:
Gender:F
Credentials:PHD LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1422 LINCOLN DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75500-1400
Mailing Address - Country:US
Mailing Address - Phone:972-245-4192
Mailing Address - Fax:
Practice Address - Street 1:1422 LINCOLN DR
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75500-1400
Practice Address - Country:US
Practice Address - Phone:972-245-4192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
00S7UTOtherBCBS TX
TXLP0008754Medicaid
00S7UTOtherBCBS TX