Provider Demographics
NPI:1396726311
Name:GUSINOV, IRINA LOLA (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:MRS
First Name:IRINA
Middle Name:LOLA
Last Name:GUSINOV
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 TAFT AVE
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-4152
Mailing Address - Country:US
Mailing Address - Phone:781-861-7552
Mailing Address - Fax:
Practice Address - Street 1:100 CUMMINGS CTR
Practice Address - Street 2:SUITE 207H
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-6115
Practice Address - Country:US
Practice Address - Phone:978-927-0907
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9318225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0395820Medicaid