Provider Demographics
NPI:1609532902
Name:ROBITAILLE, MANDY MARIE
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:MARIE
Last Name:ROBITAILLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3613 CHAIN BRIDGE RD STE D
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-3238
Mailing Address - Country:US
Mailing Address - Phone:404-455-1219
Mailing Address - Fax:
Practice Address - Street 1:3613 CHAIN BRIDGE RD STE D
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-3238
Practice Address - Country:US
Practice Address - Phone:703-397-8163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-10
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical