Provider Demographics
NPI:1780078030
Name:HERBERT, GRETTA (OFFICE ADMINISTRATOR)
Entity type:Individual
Prefix:
First Name:GRETTA
Middle Name:
Last Name:HERBERT
Suffix:
Gender:F
Credentials:OFFICE ADMINISTRATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3620 JOSEPH SIEWICK DR
Mailing Address - Street 2:SUITE 307
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-1756
Mailing Address - Country:US
Mailing Address - Phone:703-281-1023
Mailing Address - Fax:703-620-2331
Practice Address - Street 1:3620 JOSEPH SIEWICK DR
Practice Address - Street 2:SUITE 307
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1756
Practice Address - Country:US
Practice Address - Phone:703-281-1023
Practice Address - Fax:703-620-2331
Is Sole Proprietor?:No
Enumeration Date:2015-03-25
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA541148368174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1063443802Other1063443802