MEDICARE: AZIM ROLAND ROSS LPC

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	101YM0800X	Mental Health Counselor	0701011405	VA

General Provider Information

NPI Number	:	1770284234
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AZIM ROLAND ROSS LPC

Provider Business Mailing Address
First Line	:	2605 BEACON HILL RD
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22306-1611
Country	:	US
Telephone Number	:	571-459-9092
Fax Number	:

Provider Business Practice Location Address
First Line	:	2605 BEACON HILL RD
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22306-1611
Country	:	US
Telephone Number	:	571-459-9092
Fax Number	:

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

Provider Enumeration Date	:	03/13/2023
Last Update Date	:	03/13/2023

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