Provider Demographics
NPI:1417080466
Name:IVANOV, IRINA (LSW)
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:IVANOV
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 ETHEL ROAD
Mailing Address - Street 2:SUITE 404
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817
Mailing Address - Country:US
Mailing Address - Phone:732-287-4044
Mailing Address - Fax:732-287-0211
Practice Address - Street 1:4 ETHEL ROAD
Practice Address - Street 2:SUITE 404
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08817
Practice Address - Country:US
Practice Address - Phone:732-287-4044
Practice Address - Fax:732-287-0211
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05223100104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker