Provider Demographics
NPI:1184918401
Name:PAVLICEK, MARTINA (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARTINA
Middle Name:
Last Name:PAVLICEK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 YOAKUM PKWY UNIT 1802
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-3852
Mailing Address - Country:US
Mailing Address - Phone:202-744-4065
Mailing Address - Fax:
Practice Address - Street 1:11130 FAIRFAX BLVD STE 305
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-5035
Practice Address - Country:US
Practice Address - Phone:703-691-1326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-03
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810004418103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical