Basic Information
| Provider Information | |||||||||
| NPI: | 1942971619 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHATIB | ||||||||
| FirstName: | IMAN | ||||||||
| MiddleName: | FATIMA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11484 WASHINGTON PLZ W STE 300 | ||||||||
| Address2: | |||||||||
| City: | RESTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201904342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7034432000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11484 WASHINGTON PLZ W STE 300 | ||||||||
| Address2: | |||||||||
| City: | RESTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201904342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7034432000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2021 | ||||||||
| LastUpdateDate: | 09/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 0701010420 | VA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.