Provider Demographics
NPI:1164765269
Name:ROMAN, MARIAM (MA, LAC)
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:ROMAN
Suffix:
Gender:F
Credentials:MA, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6601 CENTRAL FLORIDA PKWY
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32821-8064
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7525 MITCHELL RD
Practice Address - Street 2:SUITE 100
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-1959
Practice Address - Country:US
Practice Address - Phone:952-224-2282
Practice Address - Fax:952-224-2284
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health