Provider Demographics
NPI:1821589011
Name:KHAIMOVICH, IRINA
Entity type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:KHAIMOVICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:IRINA
Other - Middle Name:
Other - Last Name:POLTORAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2819 W 12TH ST APT 3N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-3118
Mailing Address - Country:US
Mailing Address - Phone:917-420-3883
Mailing Address - Fax:
Practice Address - Street 1:2571 E 17TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-3585
Practice Address - Country:US
Practice Address - Phone:929-371-2131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NY1823038241174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator