Healthcare Provider Details

I. General information

NPI: 1992618011
Provider Name (Legal Business Name): PRINCESS JOHANNE MORTA MABUTE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1785 S HAYES ST
ARLINGTON VA
22202-2714
US

IV. Provider business mailing address

201 RANDOLPH AVE
ELKINS WV
26241-3928
US

V. Phone/Fax

Practice location:
  • Phone: 703-920-5700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP062342T
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: