Provider Demographics
NPI:1780650366
Name:MARIANO, TOMAS (PHD)
Entity Type:Individual
Prefix:
First Name:TOMAS
Middle Name:
Last Name:MARIANO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5406 N LAKE DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-2628
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:213 MCCLANAHAN ST SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-1762
Practice Address - Country:US
Practice Address - Phone:540-981-8951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810-001233103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1780650366Medicaid
VA1780650366Medicaid
VA017299C19Medicare PIN