Provider Demographics
NPI:1578171096
Name:BISONO, TANIA (QMPH-T, BS)
Entity Type:Individual
Prefix:
First Name:TANIA
Middle Name:
Last Name:BISONO
Suffix:
Gender:F
Credentials:QMPH-T, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5589 DUNLOE DR APT 201
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-3192
Mailing Address - Country:US
Mailing Address - Phone:203-524-3775
Mailing Address - Fax:
Practice Address - Street 1:1805 AIRLINE BLVD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-3912
Practice Address - Country:US
Practice Address - Phone:203-524-3775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty