Provider Demographics
NPI:1306895032
Name:PONOMARENKO, TANIA (LCSW)
Entity type:Individual
Prefix:
First Name:TANIA
Middle Name:
Last Name:PONOMARENKO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6842 ELM ST STE 104
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-3844
Mailing Address - Country:US
Mailing Address - Phone:703-752-4178
Mailing Address - Fax:
Practice Address - Street 1:6842 ELM ST STE 104
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-3844
Practice Address - Country:US
Practice Address - Phone:703-752-4178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040020591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008932018Medicaid
DCF087 0001OtherBLUECROSS BLUESHIELD
VA138370OtherBLUECROSS BLUESHIELD
VA008932018Medicaid
DCF087 0001OtherBLUECROSS BLUESHIELD