Provider Demographics
NPI:1144695180
Name:GONCHAROV, OLGA (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:OLGA
Middle Name:
Last Name:GONCHAROV
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43255 STILLFOREST TER
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-5138
Mailing Address - Country:US
Mailing Address - Phone:248-470-5774
Mailing Address - Fax:
Practice Address - Street 1:43255 STILLFOREST TER.
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147
Practice Address - Country:US
Practice Address - Phone:248-470-5774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202006930235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist