Provider Demographics
NPI:1194847327
Name:OUCHAKOV, SVETLANA
Entity Type:Individual
Prefix:MS
First Name:SVETLANA
Middle Name:
Last Name:OUCHAKOV
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 1:1731 TORREY PINES CT
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-4829
Mailing Address - Country:US
Mailing Address - Phone:703-862-6314
Mailing Address - Fax:
Practice Address - Street 1:1731 TORREY PINES CT
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-4829
Practice Address - Country:US
Practice Address - Phone:703-862-6314
Practice Address - Fax:703-774-3143
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0721961171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0104193617Medicaid