Healthcare Provider Details

I. General information

NPI: 1659199255
Provider Name (Legal Business Name): KARLY GRACE GUDYKUNST OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2024
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 SHAWNEE RD STE 104
ALEXANDRIA VA
22312-2300
US

IV. Provider business mailing address

4209 RIDGE TOP RD APT 459
FAIRFAX VA
22030-1122
US

V. Phone/Fax

Practice location:
  • Phone: 703-256-4830
  • Fax:
Mailing address:
  • Phone: 570-702-5781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119010664
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: