Provider Demographics
NPI:1457968026
Name:REPOLLET, ANTONIA MARIE (PSYD)
Entity type:Individual
Prefix:DR
First Name:ANTONIA
Middle Name:MARIE
Last Name:REPOLLET
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 1:5244 LYNGATE CT STE 200
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-1631
Mailing Address - Country:US
Mailing Address - Phone:703-910-2577
Mailing Address - Fax:
Practice Address - Street 1:5244 LYNGATE CT STE 200
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-1631
Practice Address - Country:US
Practice Address - Phone:703-910-2577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025710103T00000X
MTPSY-PSY-LIC-5083103T00000X
VA0810008547103TC0700X
NJ1027950103TS0200X
NJ35SI00712100103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool