Provider Demographics
NPI:1598984833
Name:POLONCHAK, CATHY (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:CATHY
Middle Name:
Last Name:POLONCHAK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1784
Mailing Address - Street 2:
Mailing Address - City:SHEPHERDSTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:25443-1784
Mailing Address - Country:US
Mailing Address - Phone:304-876-3022
Mailing Address - Fax:304-876-1421
Practice Address - Street 1:129 E. GERMAN ST.
Practice Address - Street 2:
Practice Address - City:SHEPHERDSTOWN
Practice Address - State:WV
Practice Address - Zip Code:25443-1784
Practice Address - Country:US
Practice Address - Phone:304-876-3022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD106811041C0700X
WVDP009408601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical