Provider Demographics
NPI:1033369186
Name:KIANIMANESH, BITA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BITA
Middle Name:
Last Name:KIANIMANESH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2239F TACKETTS MILL DR
Mailing Address - Street 2:
Mailing Address - City:LAKE RIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-3026
Mailing Address - Country:US
Mailing Address - Phone:703-490-0336
Mailing Address - Fax:
Practice Address - Street 1:2239F TACKETTS MILL DR
Practice Address - Street 2:
Practice Address - City:LAKE RIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-3026
Practice Address - Country:US
Practice Address - Phone:703-490-0336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-25
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 7802103T00000X
VA0810004039103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist