Healthcare Provider Details

I. General information

NPI: 1063450419
Provider Name (Legal Business Name): JANICE K. MARINE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JANICE K FOESS MARINE LCSW

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 11/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 E CENTER AVE
MOORESVILLE NC
28115-2578
US

IV. Provider business mailing address

610 E CENTER AVE
MOORESVILLE NC
28115-2578
US

V. Phone/Fax

Practice location:
  • Phone: 704-402-1060
  • Fax: 704-406-1065
Mailing address:
  • Phone: 704-660-1020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC004567
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: