Healthcare Provider Details

I. General information

NPI: 1649969940
Provider Name (Legal Business Name): GABRIELLE HOLDER LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2023
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2938 UPTON STREET NW BLDG 2
WASHINGTON DC
20008-1151
US

IV. Provider business mailing address

2938 UPTON STREET NW BLDG 2
WASHINGTON DC
20008-1151
US

V. Phone/Fax

Practice location:
  • Phone: 202-999-5242
  • Fax: 914-219-1084
Mailing address:
  • Phone: 202-999-5242
  • Fax: 914-219-1084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberLC50080704
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberLC50080704
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberLC50080704
License Number StateDC
# 4
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLC50080704
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: