Healthcare Provider Details

I. General information

NPI: 1174449490
Provider Name (Legal Business Name): IVY MILLS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10640 PAGE AVE STE 130
FAIRFAX VA
22030-4012
US

IV. Provider business mailing address

1158 FIELDVIEW DR
RESTON VA
20194-1047
US

V. Phone/Fax

Practice location:
  • Phone: 571-447-6048
  • Fax:
Mailing address:
  • Phone: 703-598-1757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0704019204
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: