Provider Demographics
NPI:1093584179
Name:IMTIAZ, MARIYAM (LCSW)
Entity Type:Individual
Prefix:
First Name:MARIYAM
Middle Name:
Last Name:IMTIAZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 BELLA KATY DR
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-6819
Mailing Address - Country:US
Mailing Address - Phone:832-717-7166
Mailing Address - Fax:832-717-9605
Practice Address - Street 1:147 BELLA KATY DR
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-6819
Practice Address - Country:US
Practice Address - Phone:832-717-7166
Practice Address - Fax:832-717-9605
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-29
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX697131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical