Provider Demographics
NPI:1710236237
Name:EVMENENKO, IRINA (MS/OT)
Entity Type:Individual
Prefix:MS
First Name:IRINA
Middle Name:
Last Name:EVMENENKO
Suffix:
Gender:F
Credentials:MS/OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 E 17TH ST APT C5
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-2142
Mailing Address - Country:US
Mailing Address - Phone:646-204-6811
Mailing Address - Fax:
Practice Address - Street 1:4302 NEW UTRECHT AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-1831
Practice Address - Country:US
Practice Address - Phone:718-686-9600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP83166225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist