Provider Demographics
NPI:1336458041
Name:MAVROIDIS, IRENE CARROS
Entity Type:Individual
Prefix:MRS
First Name:IRENE
Middle Name:CARROS
Last Name:MAVROIDIS
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 1:1101 REAL QUIET LN
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-6586
Mailing Address - Country:US
Mailing Address - Phone:704-400-7644
Mailing Address - Fax:704-243-2676
Practice Address - Street 1:2410 LORD ANSON DR
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-6808
Practice Address - Country:US
Practice Address - Phone:704-651-5148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-29
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist