Provider Demographics
NPI:1396178968
Name:MIRKIN, ILIA
Entity Type:Individual
Prefix:
First Name:ILIA
Middle Name:
Last Name:MIRKIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1631 STUART ST APT A
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-2190
Mailing Address - Country:US
Mailing Address - Phone:415-578-6484
Mailing Address - Fax:
Practice Address - Street 1:13585 SAN PABLO AVE
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806
Practice Address - Country:US
Practice Address - Phone:510-942-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-18
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA828471041C0700X
CA675221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical