Provider Demographics
NPI:1013790807
Name:TKACHENKO, MARIYA
Entity Type:Individual
Prefix:
First Name:MARIYA
Middle Name:
Last Name:TKACHENKO
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 1:1821 LAKE TAHOE BLVD
Mailing Address - Street 2:APT. AA7
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150
Mailing Address - Country:US
Mailing Address - Phone:925-448-0713
Mailing Address - Fax:
Practice Address - Street 1:755 N ROOP ST STE 101
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89701-3107
Practice Address - Country:US
Practice Address - Phone:775-841-6050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCI5318101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health