Provider Demographics
NPI:1164785044
Name:KHURTSILAVA, IRMA (MS ED)
Entity Type:Individual
Prefix:MS
First Name:IRMA
Middle Name:
Last Name:KHURTSILAVA
Suffix:
Gender:F
Credentials:MS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2028 GATES AVE
Mailing Address - Street 2:APT 1R
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-3003
Mailing Address - Country:US
Mailing Address - Phone:646-239-3131
Mailing Address - Fax:
Practice Address - Street 1:2028 GATES AVE
Practice Address - Street 2:APT. 1R
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-3003
Practice Address - Country:US
Practice Address - Phone:646-239-3131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-16
Last Update Date:2012-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY836528252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency