MEDICARE: NEZHLA BOZORGMAND MOMAYEZI

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	101YP2500X	Professional Counselor	LC12438	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	UNKNOWN	OTHER	MD	UNKNOWN
2	UNKNOWN	OTHER		UNKNOWN

General Provider Information

NPI Number	:	1710611389
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NEZHLA BOZORGMAND MOMAYEZI

Provider Business Mailing Address
First Line	:	15107 INTERLACHEN DR # 2-703
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20906-5625
Country	:	US
Telephone Number	:	410-978-0001
Fax Number	:

Provider Business Practice Location Address
First Line	:	15107 INTERLACHEN DR # 2-703
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20906-5625
Country	:	US
Telephone Number	:	301-455-8935
Fax Number	:

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

Provider Enumeration Date	:	07/11/2022
Last Update Date	:	05/13/2026

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