Healthcare Provider Details

I. General information

NPI: 1609714377
Provider Name (Legal Business Name): GREGORY PODOLAK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2026
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 THOMPSON ST STE E
ASHLAND VA
23005-1527
US

IV. Provider business mailing address

112 THOMPSON ST STE E
ASHLAND VA
23005-1527
US

V. Phone/Fax

Practice location:
  • Phone: 804-867-7474
  • Fax:
Mailing address:
  • Phone: 804-867-7474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904020165
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: