Provider Demographics
NPI:1598462061
Name:ISMAIL, AMIR MAHMOUD
Entity Type:Individual
Prefix:
First Name:AMIR
Middle Name:MAHMOUD
Last Name:ISMAIL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4407 PEMBROOK VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22309-1864
Mailing Address - Country:US
Mailing Address - Phone:929-309-9560
Mailing Address - Fax:
Practice Address - Street 1:7400 BEAUFONT SPRINGS DR STE 300
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23225-5519
Practice Address - Country:US
Practice Address - Phone:804-201-9082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-22-244573106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician