Healthcare Provider Details

I. General information

NPI: 1780943761
Provider Name (Legal Business Name): ALEXANDRA YADIRA CAMPOS MARTIN PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2012
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4850 MARK CENTER DR
ALEXANDRIA VA
22311-1882
US

IV. Provider business mailing address

4850 MARK CENTER DR
ALEXANDRIA VA
22311-1882
US

V. Phone/Fax

Practice location:
  • Phone: 703-746-3505
  • Fax:
Mailing address:
  • Phone: 703-746-3400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810005167
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number002838
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: