Healthcare Provider Details

I. General information

NPI: 1518384890
Provider Name (Legal Business Name): MARITA REPOLE ED.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2014
Last Update Date: 03/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 WASHINGTON AVE
DANBURY CT
06810-7927
US

IV. Provider business mailing address

44 WASHINGTON AVE
DANBURY CT
06810-7927
US

V. Phone/Fax

Practice location:
  • Phone: 203-748-5453
  • Fax:
Mailing address:
  • Phone: 203-748-5453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number001123
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: