Healthcare Provider Details

I. General information

NPI: 1326191982
Provider Name (Legal Business Name): IRYNA YUSUPOVA LOPEZ M.A., ITDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3261 US HWY 441 UNIT B3
FRUITLAND PARK FL
34731
US

IV. Provider business mailing address

1526 PROVIDENCE CIR
ORLANDO FL
32818-5708
US

V. Phone/Fax

Practice location:
  • Phone: 352-323-0612
  • Fax:
Mailing address:
  • Phone: 352-394-0212
  • Fax: 352-241-6361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: