Provider Demographics
NPI:1427571629
Name:IKUMA, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:IKUMA
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 1:9663 MAIN ST STE D
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-3758
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9663 MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-3758
Practice Address - Country:US
Practice Address - Phone:703-303-8832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-19
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701006987101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional