Provider Demographics
NPI:1114662749
Name:DEMINA, INNA
Entity Type:Individual
Prefix:
First Name:INNA
Middle Name:
Last Name:DEMINA
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 1:5180 CAMERON FOREST PKWY
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-4597
Mailing Address - Country:US
Mailing Address - Phone:786-417-3580
Mailing Address - Fax:
Practice Address - Street 1:3775 VENTURE DR UNIT M
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-5102
Practice Address - Country:US
Practice Address - Phone:470-610-4222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-28
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst