Provider Demographics
NPI:1811095011
Name:DETATA, IRINA (RPT)
Entity type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:DETATA
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 1:4331 SW 73RD TER
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33314-3030
Mailing Address - Country:US
Mailing Address - Phone:954-445-4745
Mailing Address - Fax:
Practice Address - Street 1:4331 SW 73RD TER
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33314-3030
Practice Address - Country:US
Practice Address - Phone:954-445-4745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT20047225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT20047OtherLICENSE NUMBER