Healthcare Provider Details

I. General information

NPI: 1801678735
Provider Name (Legal Business Name): ATHANASIA KYRIAZIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2023
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4140 OLD WASHINGTON RD
WALDORF MD
20602-3221
US

IV. Provider business mailing address

9906 AURA AVE APT SUITE
NORTHRIDGE CA
91324-1101
US

V. Phone/Fax

Practice location:
  • Phone: 310-645-2813
  • Fax:
Mailing address:
  • Phone: 818-885-8410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number11786
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202012092
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number34309
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: