Provider Demographics
NPI:1578132452
Name:ALEKSEYEVA, IRINA
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:ALEKSEYEVA
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 1:1241 MONTEGO APT 22
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-2843
Mailing Address - Country:US
Mailing Address - Phone:650-483-5684
Mailing Address - Fax:
Practice Address - Street 1:710 S BROADWAY STE 250
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-5234
Practice Address - Country:US
Practice Address - Phone:925-314-5767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF5136887OtherDRIVER LICENSE