MEDICARE: MS. NIDA ITTAYEM AMAL PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	0810006405	VA

General Provider Information

NPI Number	:	1255490439
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. NIDA ITTAYEM AMAL PSY.D.

Provider Business Mailing Address
First Line	:	133 PARK ST NE
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22180-4666
Country	:	US
Telephone Number	:	703-281-2657
Fax Number	:

Provider Business Practice Location Address
First Line	:	133 PARK ST NE
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22180-4666
Country	:	US
Telephone Number	:	703-281-2657
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/06/2006
Last Update Date	:	01/11/2022

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