Provider Demographics
NPI:1255490439
Name:AMAL, NIDA ITTAYEM (PSYD)
Entity Type:Individual
Prefix:MS
First Name:NIDA
Middle Name:ITTAYEM
Last Name:AMAL
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 1:133 PARK ST NE
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-4666
Mailing Address - Country:US
Mailing Address - Phone:703-281-2657
Mailing Address - Fax:
Practice Address - Street 1:133 PARK ST NE
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4666
Practice Address - Country:US
Practice Address - Phone:703-281-2657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810006405103TC0700X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical