Provider Demographics
NPI:1326191982
Name:YUSUPOVA LOPEZ, IRYNA (MA, ITDS)
Entity Type:Individual
Prefix:MS
First Name:IRYNA
Middle Name:
Last Name:YUSUPOVA LOPEZ
Suffix:
Gender:F
Credentials:MA, ITDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1526 PROVIDENCE CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32818-5708
Mailing Address - Country:US
Mailing Address - Phone:352-394-0212
Mailing Address - Fax:352-241-6361
Practice Address - Street 1:3261 US HWY 441 UNIT B3
Practice Address - Street 2:
Practice Address - City:FRUITLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:34731
Practice Address - Country:US
Practice Address - Phone:352-323-0612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL811804300Medicaid