Provider Demographics
NPI:1982278222
Name:GONCHARENKO, ANASTASIIA MAY (SUDP)
Entity type:Individual
Prefix:
First Name:ANASTASIIA
Middle Name:MAY
Last Name:GONCHARENKO
Suffix:
Gender:
Credentials:SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6926 NE FOURTH PLAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-7254
Mailing Address - Country:US
Mailing Address - Phone:360-993-3000
Mailing Address - Fax:
Practice Address - Street 1:1601 E FOURTH PLAIN BLVD BLDG 17
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-3717
Practice Address - Country:US
Practice Address - Phone:360-558-5795
Practice Address - Fax:360-397-8494
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-19
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP61647604101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)