Healthcare Provider Details

I. General information

NPI: 1043144207
Provider Name (Legal Business Name): LILLIE H MARINO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 FULLWOOD RD
MATTHEWS NC
28105-2659
US

IV. Provider business mailing address

5117 FRIENDLY BAPTIST CH RD
INDIAN TRAIL NC
28079-7794
US

V. Phone/Fax

Practice location:
  • Phone: 704-841-4920
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: