Basic Information
| Provider Information | |||||||||
| NPI: | 1366753568 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAKHALOVA | ||||||||
| FirstName: | IRINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9963 66TH AVE APT A15 | ||||||||
| Address2: | |||||||||
| City: | REGO PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113743626 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1651 CONEY ISLAND AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112305849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189981415 | ||||||||
| FaxNumber: | 7186270040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2010 | ||||||||
| LastUpdateDate: | 02/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.