Provider Demographics
NPI:1063074896
Name:PORCELLI, GINA MARIE
Entity type:Individual
Prefix:MISS
First Name:GINA
Middle Name:MARIE
Last Name:PORCELLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10520 ABBERLY VILLAGE LN APT 123
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-2728
Mailing Address - Country:US
Mailing Address - Phone:540-604-7528
Mailing Address - Fax:
Practice Address - Street 1:9833 PATRIOT HWY
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-9422
Practice Address - Country:US
Practice Address - Phone:540-847-1936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA106S00000X
VA0133003729103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician