Provider Demographics
NPI:1376573469
Name:GRANDELA, JORGE EDUARDO (MA/PSYD)
Entity Type:Individual
Prefix:MR
First Name:JORGE
Middle Name:EDUARDO
Last Name:GRANDELA
Suffix:
Gender:M
Credentials:MA/PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3930 SEEMAN RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-2457
Mailing Address - Country:US
Mailing Address - Phone:757-498-8138
Mailing Address - Fax:
Practice Address - Street 1:79 E. WINDSOR BLVD
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:VA
Practice Address - Zip Code:23487
Practice Address - Country:US
Practice Address - Phone:757-242-9988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710101723101YA0400X
VA0718000171101YA0400X
VA0701002347101YM0800X
VA0717001060106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist