Healthcare Provider Details

I. General information

NPI: 1558102186
Provider Name (Legal Business Name): MR. JOSE GBABA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2024
Last Update Date: 06/06/2024
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6408 GROVEDALE DR STE 204
ALEXANDRIA VA
22310-2596
US

IV. Provider business mailing address

6408 GROVEDALE DR STE 204
ALEXANDRIA VA
22310-2596
US

V. Phone/Fax

Practice location:
  • Phone: 301-767-1733
  • Fax:
Mailing address:
  • Phone: 301-767-1733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: