Provider Demographics
NPI:1649867367
Name:SAFIARDESTANI, ROSHANAK
Entity type:Individual
Prefix:
First Name:ROSHANAK
Middle Name:
Last Name:SAFIARDESTANI
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 1:2235 CEDAR LN STE 102
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-5247
Mailing Address - Country:US
Mailing Address - Phone:703-556-4888
Mailing Address - Fax:
Practice Address - Street 1:2235 CEDAR LN STE 102
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-5247
Practice Address - Country:US
Practice Address - Phone:703-556-4888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-29
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0134000355106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst