Provider Demographics
NPI:1396178968
Name:MIRKIN, ILIA
Entity type:Individual
Prefix:
First Name:ILIA
Middle Name:
Last Name:MIRKIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 ANZA ST APT 404
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94118-4390
Mailing Address - Country:US
Mailing Address - Phone:415-275-2496
Mailing Address - Fax:
Practice Address - Street 1:400 ANZA ST APT 404
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-4390
Practice Address - Country:US
Practice Address - Phone:415-275-2496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-18
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI042561041C0700X
FLSW245851041C0700X
MAISW042561041C0700X
VA9040184161041C0700X
CA828471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical