Healthcare Provider Details

I. General information

NPI: 1932668472
Provider Name (Legal Business Name): IDA DAMKILDE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2019
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 DEWITT LOOP
FORT BELVOIR VA
22060-5285
US

IV. Provider business mailing address

3025 HAMAKER CT STE 450
FAIRFAX VA
22031-2237
US

V. Phone/Fax

Practice location:
  • Phone: 571-231-1803
  • Fax:
Mailing address:
  • Phone: 703-204-9100
  • Fax: 301-468-1862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number0904013564
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: