Provider Demographics
NPI:1558727396
Name:DERKACHEVA, IRINA (MPS, LCAT)
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:DERKACHEVA
Suffix:
Gender:F
Credentials:MPS, LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 SPENCER CT APT 4D
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11205-4825
Mailing Address - Country:US
Mailing Address - Phone:240-506-0378
Mailing Address - Fax:
Practice Address - Street 1:5 SPENCER CT APT 4D
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11205-4825
Practice Address - Country:US
Practice Address - Phone:240-506-0378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-09
Last Update Date:2016-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001811101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor