MEDICARE: DEBORAH SUSAN MARINO MED

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	1219428	FL
2	101YS0200X	School Counselor	1219428	FL

General Provider Information

NPI Number	:	1386189025
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEBORAH SUSAN MARINO MED

Provider Business Mailing Address
First Line	:	1830 BRANTLEY RD
Second Line	:	BUILDING C UNIT 8
City	:	FORT MYERS
State	:	FL
Zip	:	33907-3938
Country	:	US
Telephone Number	:	239-850-5697
Fax Number	:

Provider Business Practice Location Address
First Line	:	1830 BRANTLEY RD
Second Line	:	BUILDING C UNIT 8
City	:	FORT MYERS
State	:	FL
Zip	:	33907-3938
Country	:	US
Telephone Number	:	239-850-5697
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/04/2017
Last Update Date	:	01/04/2017

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