Healthcare Provider Details

I. General information

NPI: 1457968026
Provider Name (Legal Business Name): ANTONIA MARIE REPOLLET PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2020
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5244 LYNGATE CT STE 200
BURKE VA
22015-1631
US

IV. Provider business mailing address

5244 LYNGATE CT STE 200
BURKE VA
22015-1631
US

V. Phone/Fax

Practice location:
  • Phone: 703-910-2577
  • Fax:
Mailing address:
  • Phone: 703-910-2577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number025710
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY-PSY-LIC-5083
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810008547
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1027950
License Number StateNJ
# 5
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number35SI00712100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: