MEDICARE: MITRA SHAHRYARY 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	0904009965	VA

General Provider Information

NPI Number	:	1487349395
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MITRA SHAHRYARY LCSW

Provider Business Mailing Address
First Line	:	278 CEDAR LN SE # 4112
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22180-6613
Country	:	US
Telephone Number	:	202-750-1138
Fax Number	:

Provider Business Practice Location Address
First Line	:	278 CEDAR LN SE # 4112
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22180-6613
Country	:	US
Telephone Number	:	202-750-1138
Fax Number	:

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

Provider Enumeration Date	:	04/06/2023
Last Update Date	:	10/17/2025

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