Provider Demographics
NPI:1659199255
Name:GUDYKUNST, KARLY GRACE (OTR)
Entity type:Individual
Prefix:MS
First Name:KARLY
Middle Name:GRACE
Last Name:GUDYKUNST
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4209 RIDGE TOP RD APT 459
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-1122
Mailing Address - Country:US
Mailing Address - Phone:570-702-5781
Mailing Address - Fax:
Practice Address - Street 1:5400 SHAWNEE RD STE 104
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22312-2300
Practice Address - Country:US
Practice Address - Phone:703-256-4830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119010664225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist