Provider Demographics
NPI:1184240889
Name:IWANOW, DEBRA (ATC, CSCS)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:IWANOW
Suffix:
Gender:F
Credentials:ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 DELVIEW TER
Mailing Address - Street 2:
Mailing Address - City:DELHI
Mailing Address - State:NY
Mailing Address - Zip Code:13753-1056
Mailing Address - Country:US
Mailing Address - Phone:607-592-1225
Mailing Address - Fax:
Practice Address - Street 1:169 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-4246
Practice Address - Country:US
Practice Address - Phone:607-592-1225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL30192255A2300X
NY0012342255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY001234OtherNEW YORK STATE LICENSE
FLAL3019OtherFLORIDA STATE LICENSE