Healthcare Provider Details

I. General information

NPI: 1154257541
Provider Name (Legal Business Name): GELAREH BASSIRY QMHP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6340 DRACO ST
BURKE VA
22015-3552
US

IV. Provider business mailing address

6340 DRACO ST
BURKE VA
22015-3552
US

V. Phone/Fax

Practice location:
  • Phone: 571-354-5971
  • Fax:
Mailing address:
  • Phone: 571-354-5971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0732011049
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: