Provider Demographics
NPI:1558074757
Name:NASROLLAHI, MITRA
Entity Type:Individual
Prefix:
First Name:MITRA
Middle Name:
Last Name:NASROLLAHI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 LONGFELLOW ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-3015
Mailing Address - Country:US
Mailing Address - Phone:818-579-3366
Mailing Address - Fax:
Practice Address - Street 1:502 KENNEDY ST NW STE 2-A
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-3136
Practice Address - Country:US
Practice Address - Phone:202-743-4884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-03
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLGPC20000007101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional