Basic Information
| Provider Information | |||||||||
| NPI: | 1932668472 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAMKILDE | ||||||||
| FirstName: | IDA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3025 HAMAKER CT STE 450 | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220312237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032049100 | ||||||||
| FaxNumber: | 3014681862 | ||||||||
| Practice Location | |||||||||
| Address1: | 3025 HAMAKER CT STE 450 | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220312237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032049100 | ||||||||
| FaxNumber: | 3014681862 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2019 | ||||||||
| LastUpdateDate: | 12/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 0906009040 | VA | N | Behavioral Health & Social Service Providers | Social Worker | 104100000X | VA | N | Behavioral Health & Social Service Providers | Social Worker | 104100000X | 0904013564 | VA | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.