Healthcare Provider Details

I. General information

NPI: 1780770537
Provider Name (Legal Business Name): MARY S ZIMOMRA LPC, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY SUZETTE ZIMOMRA LPC

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12007 SUNRISE VALLEY DR STE 300
RESTON VA
20191-3446
US

IV. Provider business mailing address

12007 SUNRISE VALLEY DR STE 300
RESTON VA
20191-3446
US

V. Phone/Fax

Practice location:
  • Phone: 804-207-6737
  • Fax:
Mailing address:
  • Phone: 804-207-6737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701001964
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0717000883
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: