Provider Demographics
NPI:1023507043
Name:KOUFALIS, IRENE (LMT)
Entity type:Individual
Prefix:MS
First Name:IRENE
Middle Name:
Last Name:KOUFALIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 367
Mailing Address - Street 2:
Mailing Address - City:EAST TEXAS
Mailing Address - State:PA
Mailing Address - Zip Code:18046
Mailing Address - Country:US
Mailing Address - Phone:610-530-2003
Mailing Address - Fax:610-398-8828
Practice Address - Street 1:5620 EAST TEXAS ROAD
Practice Address - Street 2:
Practice Address - City:EAST TEXAS
Practice Address - State:PA
Practice Address - Zip Code:18046
Practice Address - Country:US
Practice Address - Phone:610-530-2203
Practice Address - Fax:610-398-8828
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-04
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG004776225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist