Healthcare Provider Details

I. General information

NPI: 1821585100
Provider Name (Legal Business Name): ANDREW INTAGLIATA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2018
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 BRADDOCK PL
ALEXANDRIA VA
22314-1693
US

IV. Provider business mailing address

8326 LINDSIDE WAY
SPRINGFIELD VA
22153-3523
US

V. Phone/Fax

Practice location:
  • Phone: 703-706-4460
  • Fax:
Mailing address:
  • Phone: 540-810-4174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberPPS-0603682
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: