1740386762 NPI number — PIMMIT COUNSELING & WELLNESS CLINIC PLLC

Table of content: (NPI 1740386762)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740386762 NPI number — PIMMIT COUNSELING & WELLNESS CLINIC PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PIMMIT COUNSELING & WELLNESS CLINIC PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PIMMIT COUNSELING & WELLNESS CLINIC
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740386762
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2235 CEDAR LN STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIENNA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22182-5247
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-556-4888
Provider Business Mailing Address Fax Number:
703-556-7774

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2235 CEDAR LN STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VIENNA
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22182-5247
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-556-4888
Provider Business Practice Location Address Fax Number:
703-556-7774
Provider Enumeration Date:
09/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
POORSHAGHAGHI
Authorized Official First Name:
SHAHRZAD
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
703-556-4888

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  0701002934 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 005411165 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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