Provider Demographics
NPI:1902175961
Name:IAKUPOVA, REGINA (SLP)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:IAKUPOVA
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 GLENVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:ALLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02134-3443
Mailing Address - Country:US
Mailing Address - Phone:857-654-0365
Mailing Address - Fax:
Practice Address - Street 1:78 GLENVILLE AVE APT 8
Practice Address - Street 2:
Practice Address - City:ALLSTON
Practice Address - State:MA
Practice Address - Zip Code:02134-3471
Practice Address - Country:US
Practice Address - Phone:857-654-0365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-21
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MASP-8442-SL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist