Provider Demographics
NPI:1497993364
Name:KASABOV, IRINA (PT)
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:KASABOV
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18411 COLLINS ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-6515
Mailing Address - Country:US
Mailing Address - Phone:818-571-6095
Mailing Address - Fax:
Practice Address - Street 1:45 ERBES RD
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91362-5802
Practice Address - Country:US
Practice Address - Phone:805-495-4657
Practice Address - Fax:818-881-0258
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-30
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT24432OtherLICENSE