MEDICARE: MARIYAM IMTIAZ LCSW

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	1041C0700X	Clinical Social Worker	69713	TX

General Provider Information

NPI Number	:	1093584179
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIYAM IMTIAZ LCSW

Provider Business Mailing Address
First Line	:	147 BELLA KATY DR
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77494-6819
Country	:	US
Telephone Number	:	832-717-7166
Fax Number	:	832-717-9605

Provider Business Practice Location Address
First Line	:	147 BELLA KATY DR
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77494-6819
Country	:	US
Telephone Number	:	832-717-7166
Fax Number	:	832-717-9605

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

Provider Enumeration Date	:	12/29/2023
Last Update Date	:	12/29/2023

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Directions to “ MARIYAM IMTIAZ LCSW” Practice Location

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