Healthcare Provider Details

I. General information

NPI: 1104084219
Provider Name (Legal Business Name): SUMMER MORIAH RUTH PETRILLI BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2008
Last Update Date: 01/14/2022
Certification Date: 01/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10530 WARWICK AVE STE C2
FAIRFAX VA
22030-3132
US

IV. Provider business mailing address

5 RUTLEDGE CT
STERLING VA
20165-6243
US

V. Phone/Fax

Practice location:
  • Phone: 703-731-4766
  • Fax:
Mailing address:
  • Phone: 703-731-4766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number1-06-3131
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: