Healthcare Provider Details

I. General information

NPI: 1497136352
Provider Name (Legal Business Name): EKATERINA ITZEVA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2015
Last Update Date: 06/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6122 RIDGE AVE
PHILADELPHIA PA
19128-1603
US

IV. Provider business mailing address

3507 BOWMAN ST APT 4
PHILADELPHIA PA
19129-1510
US

V. Phone/Fax

Practice location:
  • Phone: 215-487-1330
  • Fax:
Mailing address:
  • Phone: 908-698-2936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: