MEDICARE: IRINA BASHKIROV LAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	37AC00246600	NJ

General Provider Information

NPI Number	:	1699161802
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IRINA BASHKIROV LAC

Provider Business Mailing Address
First Line	:	121 CHADWICK RD
Second Line	:
City	:	TEANECK
State	:	NJ
Zip	:	07666-4203
Country	:	US
Telephone Number	:	917-667-0242
Fax Number	:

Provider Business Practice Location Address
First Line	:	440 WEST ST STE 323
Second Line	:
City	:	FORT LEE
State	:	NJ
Zip	:	07024-5028
Country	:	US
Telephone Number	:	917-667-0242
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2015
Last Update Date	:	04/14/2015

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Directions to “ IRINA BASHKIROV LAC” Practice Location

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