Healthcare Provider Details

I. General information

NPI: 1356259030
Provider Name (Legal Business Name): KELLY MARIE MULDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 08/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 UNIVERSITY DR STE 130
FAIRFAX VA
22030-2513
US

IV. Provider business mailing address

23 SARASOTA DR
STAFFORD VA
22554-7815
US

V. Phone/Fax

Practice location:
  • Phone: 703-655-9880
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0704019366
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: