Ivy Petra, LCSW, LCAC

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

34006676A Issued in IN

Practice address

213 Middlebury St
Goshen, IN 46528

Phone

(574) 534-3300

Fax

(574) 534-5412

NPI assigned

Aug 12, 2013

Last updated

Dec 31, 2020By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in IN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Clinical Social Worker

Education

Other, 2009

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Maple City Health Care Center IncGroup PAC ID 2163569401, 29 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Maple City Health Care Center, Inc.

  • Federally Qualified Health Center (FQHC)
  • Goshen, IN
  • NPI 1033166095
  Medicare reassignment Care Compare group NPD
• Maple City Health Care Center, Inc

  dba Westend Community Health Center

  • Federally Qualified Health Center (FQHC)
  • Goshen, IN
  • NPI 1275220303
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1376265600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1609372800000",
    "number": "1538592704",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "213 MIDDLEBURY ST",
            "city": "GOSHEN",
            "state": "IN",
            "postal_code": "465282956",
            "telephone_number": "574-534-3300",
            "fax_number": "574-534-5412"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "213 MIDDLEBURY ST",
            "city": "GOSHEN",
            "state": "IN",
            "postal_code": "46528",
            "telephone_number": "574-534-3300",
            "fax_number": "574-534-5412"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "2600 Oakland Ave",
            "address_purpose": "LOCATION",
            "city": "Elkhart",
            "state": "IN",
            "postal_code": "465171533",
            "country_code": "US",
            "telephone_number": "574-533-1234 x488",
            "fax_number": "574-537-2652",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "808 N 3rd St",
            "address_purpose": "LOCATION",
            "city": "Goshen",
            "state": "IN",
            "postal_code": "465287100",
            "country_code": "US",
            "telephone_number": "574-534-0088",
            "fax_number": "574-971-8434",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "2600 Oakland Ave",
            "address_purpose": "LOCATION",
            "city": "Elkhart",
            "state": "IN",
            "postal_code": "465171533",
            "country_code": "US",
            "telephone_number": "574-533-1234 x488",
            "fax_number": "574-537-2652",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "PETRA",
        "first_name": "IVY",
        "credential": "LCSW, LCAC",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2013-08-12",
        "last_updated": "2020-12-31",
        "certification_date": "2020-12-31",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "IN",
            "license": "87001243A",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "IN",
            "license": "34006676A",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "ipetra299505@direct.ochin.org",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "address_1": "213 Middlebury St",
            "city": "Goshen",
            "state": "IN",
            "country_code": "US",
            "postal_code": "46528",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Carrie Pennington, MA
• Kenneth L Pennington, M.D.
• Bethany Perrin, DO
• Holli Elizabeth Perrin, MS, BCBA
• Kenneth D Petersen, M.D.
• Frank Louis Piaskowy, D.O.
• Richard E Pipher, LCSW
• Gianna L Pociask, DPT
• Amy Rebecca Pointon, MSN, RN, CNS, FNP
• Natasha Candace Pontius

• Clinical Social Worker in Goshen, IN
• Providers in Goshen, IN by specialty
• Clinical Social Worker in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 31, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.