Healthcare Provider Details

I. General information

NPI: 1487349395
Provider Name (Legal Business Name): MITRA SHAHRYARY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2023
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2725 OLDEWOOD DR
FALLS CHURCH VA
22043-3416
US

IV. Provider business mailing address

278 CEDAR LN SE # 4112
VIENNA VA
22180-6613
US

V. Phone/Fax

Practice location:
  • Phone: 703-856-3297
  • Fax:
Mailing address:
  • Phone: 202-750-1138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904009965
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: