Provider Demographics
NPI:1598216350
Name:ROMAN, ILLONA (LGSW)
Entity Type:Individual
Prefix:
First Name:ILLONA
Middle Name:
Last Name:ROMAN
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:ILLONA
Other - Middle Name:
Other - Last Name:LUKO, JEENINGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:319 FELLERS LN
Mailing Address - Street 2:
Mailing Address - City:INWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:25428-4392
Mailing Address - Country:US
Mailing Address - Phone:304-620-2666
Mailing Address - Fax:
Practice Address - Street 1:319 FELLERS LN
Practice Address - Street 2:
Practice Address - City:INWOOD
Practice Address - State:WV
Practice Address - Zip Code:25428-4392
Practice Address - Country:US
Practice Address - Phone:304-620-2666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVBP00942913101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor