Healthcare Provider Details

I. General information

NPI: 1063964286
Provider Name (Legal Business Name): MARIA MARINO AND ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2016
Last Update Date: 11/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 COUNTY ROAD 10
BROOKLYN CENTER MN
55429-3072
US

IV. Provider business mailing address

5615 100TH LN N
BROOKLYN PARK MN
55443-5700
US

V. Phone/Fax

Practice location:
  • Phone: 612-719-7298
  • Fax: 763-898-3584
Mailing address:
  • Phone: 612-719-2842
  • Fax: 763-898-3584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberLICSW 13814
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number13814
License Number StateMN

VIII. Authorized Official

Name: MARIA EUGENIA TATZMANN
Title or Position: OWNER
Credential: MSW, LICSW
Phone: 612-719-7298