Healthcare Provider Details

I. General information

NPI: 1669380739
Provider Name (Legal Business Name): IRINA SHUTAK
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 VILLAGE GREEN APT. D
BUDD LAKE NJ
07828-1304
US

IV. Provider business mailing address

4 VILLAGE GRN APT D
BUDD LAKE NJ
07828-1304
US

V. Phone/Fax

Practice location:
  • Phone: 973-216-6567
  • Fax:
Mailing address:
  • Phone: 973-216-6567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: