=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508409079
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IRINA YEGOROV LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2019
-----------------------------------------------------
Last Update Date | 10/28/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2615 E 16TH ST
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-801-4499
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2615 EAST 16TH STREET
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-801-4499
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 087807
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------