=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518384890
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARITA REPOLE ED.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2014
-----------------------------------------------------
Last Update Date | 03/25/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 44 WASHINGTON AVE
-----------------------------------------------------
City | DANBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06810-7927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-748-5453
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 44 WASHINGTON AVE
-----------------------------------------------------
City | DANBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06810-7927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-748-5453
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 001123
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------