Provider Demographics
NPI:1285663963
Name:VAKHNYANSKAYA, IRINA (PHD)
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:VAKHNYANSKAYA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 WESTMINSTER RD
Mailing Address - Street 2:1013 EAST 13 STREET APT A-10
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-2401
Mailing Address - Country:US
Mailing Address - Phone:718-258-7190
Mailing Address - Fax:
Practice Address - Street 1:5110 12TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-3424
Practice Address - Country:US
Practice Address - Phone:800-275-3243
Practice Address - Fax:800-275-3671
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016487103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV5W761Medicare ID - Type Unspecified