Provider Demographics
NPI:1871802314
Name:SIRIKIETSOONG, SARUNPORN (JAY) (PSYD)
Entity type:Individual
Prefix:DR
First Name:SARUNPORN (JAY)
Middle Name:
Last Name:SIRIKIETSOONG
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6120 BRANDON AVE STE 315
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22150-2504
Mailing Address - Country:US
Mailing Address - Phone:703-283-3325
Mailing Address - Fax:
Practice Address - Street 1:6120 BRANDON AVE STE 315
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-2504
Practice Address - Country:US
Practice Address - Phone:541-514-9884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-01
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103G00000X, 106H00000X
VA0810006183103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist