Provider Demographics
NPI:1609458330
Name:BURSAK, IRINA (OT)
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:BURSAK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7212 BALSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130-3001
Mailing Address - Country:US
Mailing Address - Phone:314-726-5600
Mailing Address - Fax:314-754-9317
Practice Address - Street 1:7212 BALSON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63130-3001
Practice Address - Country:US
Practice Address - Phone:314-726-5600
Practice Address - Fax:314-754-9317
Is Sole Proprietor?:No
Enumeration Date:2021-04-22
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005166225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist