Provider Demographics
NPI:1639235344
Name:IVANENKO, ANASTASIA (OTR/L)
Entity Type:Individual
Prefix:
First Name:ANASTASIA
Middle Name:
Last Name:IVANENKO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 HAYES LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-3703
Mailing Address - Country:US
Mailing Address - Phone:617-930-0906
Mailing Address - Fax:
Practice Address - Street 1:7 HAYES LN
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420-3703
Practice Address - Country:US
Practice Address - Phone:617-930-0906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9839225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics