Provider Demographics
NPI:1780244087
Name:IVANILOVA, YULIYA (LMT)
Entity type:Individual
Prefix:
First Name:YULIYA
Middle Name:
Last Name:IVANILOVA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:JULIYA
Other - Middle Name:
Other - Last Name:IVANILOVA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:6017 SOUTHPORT DR
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814-1847
Mailing Address - Country:US
Mailing Address - Phone:240-498-5286
Mailing Address - Fax:
Practice Address - Street 1:6017 SOUTHPORT DR
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-1847
Practice Address - Country:US
Practice Address - Phone:240-498-5286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM05622225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist