Provider Demographics
NPI:1043895253
Name:GOLOVIN, IRINA
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:GOLOVIN
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 1:29707 SE OLD RANCH DR
Mailing Address - Street 2:
Mailing Address - City:ESTACADA
Mailing Address - State:OR
Mailing Address - Zip Code:97023-9736
Mailing Address - Country:US
Mailing Address - Phone:503-975-4640
Mailing Address - Fax:
Practice Address - Street 1:806 SW BROADWAY STE 350
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-3336
Practice Address - Country:US
Practice Address - Phone:503-224-9513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR26236225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist