Provider Demographics
NPI:1497812432
Name:SACKS, CAROL RUTH (PHD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:RUTH
Last Name:SACKS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 N GEORGE MASON DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22205-3675
Mailing Address - Country:US
Mailing Address - Phone:703-228-4872
Mailing Address - Fax:703-228-5234
Practice Address - Street 1:1725 N GEORGE MASON DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205-3675
Practice Address - Country:US
Practice Address - Phone:703-228-4872
Practice Address - Fax:703-228-5234
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001753103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4945042Medicaid
VAAR410255Medicare ID - Type UnspecifiedAGENCY PROVIDER NUMBER