Provider Demographics
NPI:1720102452
Name:MIRVODA, SVETLANA (RPT)
Entity Type:Individual
Prefix:
First Name:SVETLANA
Middle Name:
Last Name:MIRVODA
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 TERRANE AVE
Mailing Address - Street 2:
Mailing Address - City:NATICK
Mailing Address - State:MA
Mailing Address - Zip Code:01760-1706
Mailing Address - Country:US
Mailing Address - Phone:508-545-2305
Mailing Address - Fax:508-545-2305
Practice Address - Street 1:20 LINDEN ST STE 1
Practice Address - Street 2:
Practice Address - City:ALLSTON
Practice Address - State:MA
Practice Address - Zip Code:02134-1776
Practice Address - Country:US
Practice Address - Phone:617-787-0030
Practice Address - Fax:617-787-0010
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10206225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0305901Medicaid
MAY68554OtherINDIVIDUAL
MAY68554OtherINDIVIDUAL