Provider Demographics
NPI:1467875328
Name:CHAN, IRENE
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:CHAN
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 1:2111 ACACIA PARK DR APT 222
Mailing Address - Street 2:
Mailing Address - City:LYNDHURST
Mailing Address - State:OH
Mailing Address - Zip Code:44124-3844
Mailing Address - Country:US
Mailing Address - Phone:646-300-1774
Mailing Address - Fax:
Practice Address - Street 1:2111 ACACIA PARK DR APT 222
Practice Address - Street 2:
Practice Address - City:LYNDHURST
Practice Address - State:OH
Practice Address - Zip Code:44124-3844
Practice Address - Country:US
Practice Address - Phone:646-300-1774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-29
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1-08-4294103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst