Basic Information
| Provider Information | |||||||||
| NPI: | 1053991885 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KAZUBA | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | DENISE | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1581 SPRING GATE DR UNIT 5112 | ||||||||
| Address2: | |||||||||
| City: | MC LEAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221023439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7039756351 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7969 ASHTON AVE | ||||||||
| Address2: | |||||||||
| City: | MANASSAS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201092885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037927826 | ||||||||
| FaxNumber: | 7037925699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2021 | ||||||||
| LastUpdateDate: | 04/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 0701010294 | VA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.