Provider Demographics
NPI:1194578609
Name:GIBSON-PRUIKSMA, GEORGIA ALEXANDRA
Entity type:Individual
Prefix:
First Name:GEORGIA
Middle Name:ALEXANDRA
Last Name:GIBSON-PRUIKSMA
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 1:22786 COURTLAND PARK DR
Mailing Address - Street 2:
Mailing Address - City:BRAMBLETON
Mailing Address - State:VA
Mailing Address - Zip Code:20148-5600
Mailing Address - Country:US
Mailing Address - Phone:571-999-3383
Mailing Address - Fax:
Practice Address - Street 1:4700 LEEWARD CT
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-2139
Practice Address - Country:US
Practice Address - Phone:434-484-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health