Provider Demographics
NPI:1487126546
Name:EBRAHIMZADEH, MARYAM (LAC)
Entity type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:EBRAHIMZADEH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11870 GRAND PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20852-8690
Mailing Address - Country:US
Mailing Address - Phone:443-474-5295
Mailing Address - Fax:
Practice Address - Street 1:11870 GRAND PARK AVE
Practice Address - Street 2:
Practice Address - City:NORTH BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20852-8690
Practice Address - Country:US
Practice Address - Phone:443-474-5295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-28
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU02547171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist