Provider Demographics
NPI:1710364591
Name:WEINGARDT, IVY
Entity type:Individual
Prefix:
First Name:IVY
Middle Name:
Last Name:WEINGARDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 MICHELLINE LN
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-2117
Mailing Address - Country:US
Mailing Address - Phone:847-559-1719
Mailing Address - Fax:
Practice Address - Street 1:613 MICHELLINE LN
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-2117
Practice Address - Country:US
Practice Address - Phone:847-559-1719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-30
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
IL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst