Healthcare Provider Details

I. General information

NPI: 1043624646
Provider Name (Legal Business Name): BROOKE PISTILLI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2014
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12563 SUMMIT MANOR DR APT 415
FAIRFAX VA
22033-5755
US

IV. Provider business mailing address

12563 SUMMIT MANOR DR APT 415
FAIRFAX VA
22033-5755
US

V. Phone/Fax

Practice location:
  • Phone: 610-207-9771
  • Fax:
Mailing address:
  • Phone: 610-207-9771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202007075
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: