Provider Demographics
NPI:1518384890
Name:REPOLE, MARITA (EDD)
Entity Type:Individual
Prefix:DR
First Name:MARITA
Middle Name:
Last Name:REPOLE
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-7927
Mailing Address - Country:US
Mailing Address - Phone:203-748-5453
Mailing Address - Fax:
Practice Address - Street 1:44 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-7927
Practice Address - Country:US
Practice Address - Phone:203-748-5453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-25
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001123101YP2500X
CT103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool