Healthcare Provider Details

I. General information

NPI: 1922866011
Provider Name (Legal Business Name): GEBAJ MENTAL HEALTH AND CORE SERVICES CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2024
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 BALTIMORE AVE #300-R9
RIVERDALE MD
20737-1054
US

IV. Provider business mailing address

6200 BALTIMORE AVE 300-R9
RIVERDALE MD
20737-1054
US

V. Phone/Fax

Practice location:
  • Phone: 240-930-0811
  • Fax: 443-272-7756
Mailing address:
  • Phone: 240-930-0811
  • Fax: 443-272-7756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: BASIL E. FOMANKA
Title or Position: CEO/OWNER
Credential: PMHNP
Phone: 443-520-8138