Provider Demographics
NPI:1336476837
Name:KHAKHAMOVA, IRINA
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:KHAKHAMOVA
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 1:10225 67TH DR APT 4V
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-2877
Mailing Address - Country:US
Mailing Address - Phone:347-645-3139
Mailing Address - Fax:
Practice Address - Street 1:10225 67TH DR APT 4V
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-2877
Practice Address - Country:US
Practice Address - Phone:347-645-3139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-04
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011893-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist