Provider Demographics
NPI:1780770537
Name:ZIMOMRA, MARY S (LPC, LMFT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:S
Last Name:ZIMOMRA
Suffix:
Gender:F
Credentials:LPC, LMFT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:SUZETTE
Other - Last Name:ZIMOMRA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:12007 SUNRISE VALLEY DR STE 300
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-3446
Mailing Address - Country:US
Mailing Address - Phone:804-207-6737
Mailing Address - Fax:
Practice Address - Street 1:12007 SUNRISE VALLEY DR STE 300
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-3446
Practice Address - Country:US
Practice Address - Phone:804-207-6737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701001964101YP2500X
VA0717000883106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30015390670007Medicaid