Healthcare Provider Details

I. General information

NPI: 1588225445
Provider Name (Legal Business Name): ASHLEY LACIK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2019
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10565 FAIRFAX BLVD STE 300
FAIRFAX VA
22030-3104
US

IV. Provider business mailing address

10565 FAIRFAX BLVD STE 300
FAIRFAX VA
22030-3104
US

V. Phone/Fax

Practice location:
  • Phone: 703-218-6599
  • Fax: --
Mailing address:
  • Phone: 703-218-6599
  • Fax: --

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number25-441703
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: