Provider Demographics
NPI:1164721080
Name:MENICK, TATIANA (MD)
Entity Type:Individual
Prefix:
First Name:TATIANA
Middle Name:
Last Name:MENICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3802 EXECUTIVE AVE
Mailing Address - Street 2:D-1
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22305-2112
Mailing Address - Country:US
Mailing Address - Phone:703-535-7930
Mailing Address - Fax:703-515-7950
Practice Address - Street 1:3802 EXECUTIVE AVE
Practice Address - Street 2:D-1
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22305-2112
Practice Address - Country:US
Practice Address - Phone:703-535-7930
Practice Address - Fax:703-515-7950
Is Sole Proprietor?:No
Enumeration Date:2011-03-17
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012488092084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry