Provider Demographics
NPI:1508543877
Name:KUKLA, KATELYN NICOLE (LCSW)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:NICOLE
Last Name:KUKLA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10520 JUDICIAL DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-5115
Mailing Address - Country:US
Mailing Address - Phone:703-246-4336
Mailing Address - Fax:
Practice Address - Street 1:10520 JUDICIAL DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-5115
Practice Address - Country:US
Practice Address - Phone:571-474-5361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-29
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040155341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical