Provider Demographics
NPI:1366216939
Name:ISJWARA, IRENE DEWI
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:DEWI
Last Name:ISJWARA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4135 RESIDENCE DR APT 611
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9228
Mailing Address - Country:US
Mailing Address - Phone:872-803-8471
Mailing Address - Fax:
Practice Address - Street 1:3661 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-8218
Practice Address - Country:US
Practice Address - Phone:872-803-8471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-14
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-25-16087106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst