Provider Demographics
NPI:1851950125
Name:FOUT, IRINA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:IRINA
Middle Name:
Last Name:FOUT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 W EAU GALLIE BLVD STE 201I
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-4149
Mailing Address - Country:US
Mailing Address - Phone:321-265-3904
Mailing Address - Fax:
Practice Address - Street 1:1600 W EAU GALLIE BLVD STE 201I
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-4149
Practice Address - Country:US
Practice Address - Phone:321-265-3904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW162851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical