Healthcare Provider Details

I. General information

NPI: 1750804571
Provider Name (Legal Business Name): JAIME LYNN MARINO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2017
Last Update Date: 08/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 MASSACHUSETTS AVE
LUNENBURG MA
01462
US

IV. Provider business mailing address

4 BROOKSIDE AVE
WORCESTER MA
01602-1609
US

V. Phone/Fax

Practice location:
  • Phone: 978-827-0757
  • Fax:
Mailing address:
  • Phone: 413-313-5277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: