Healthcare Provider Details

I. General information

NPI: 1629337969
Provider Name (Legal Business Name): REBECCA BROSCH PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2012
Last Update Date: 05/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7230 HERITAGE VILLAGE PLZ SUITE 202
GAINESVILLE VA
20155-3053
US

IV. Provider business mailing address

7230 HERITAGE VILLAGE PLZ SUITE 202
GAINESVILLE VA
20155-3053
US

V. Phone/Fax

Practice location:
  • Phone: 703-754-0636
  • Fax: 703-754-0646
Mailing address:
  • Phone: 703-754-0636
  • Fax: 703-754-0646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810004574
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: