Healthcare Provider Details

I. General information

NPI: 1740386762
Provider Name (Legal Business Name): PIMMIT COUNSELING & WELLNESS CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2235 CEDAR LN STE 102
VIENNA VA
22182-5247
US

IV. Provider business mailing address

2235 CEDAR LN STE 102
VIENNA VA
22182-5247
US

V. Phone/Fax

Practice location:
  • Phone: 703-556-4888
  • Fax: 703-556-7774
Mailing address:
  • Phone: 703-556-4888
  • Fax: 703-556-7774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701002934
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: MRS. SHAHRZAD POORSHAGHAGHI
Title or Position: OWNER
Credential: ED.D, LPC, NCC
Phone: 703-556-4888