Healthcare Provider Details

I. General information

NPI: 1992542617
Provider Name (Legal Business Name): KIMBERLY D. ISMAIL MS, BCH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2024
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13000 HARBOR DRIVE SUITE 100
WOODBRDIGE VA
22192
US

IV. Provider business mailing address

13000 HARBOR DRIVE SUITE 100
WOODBRDIGE VA
22192
US

V. Phone/Fax

Practice location:
  • Phone: 571-480-4613
  • Fax:
Mailing address:
  • Phone: 571-480-4613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: