Healthcare Provider Details

I. General information

NPI: 1861896037
Provider Name (Legal Business Name): MARINA DIPILATO PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2014
Last Update Date: 10/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 LASER RD NE RIO RANCHO PUBLIC SCHOOLS
RIO RANCHO NM
87124-4517
US

IV. Provider business mailing address

500 LASER RD NE RIO RANCHO PUBLIC SCHOOLS
RIO RANCHO NM
87124-4517
US

V. Phone/Fax

Practice location:
  • Phone: 505-896-0667
  • Fax: 505-896-0662
Mailing address:
  • Phone: 505-896-0667
  • Fax: 505-896-0662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number533
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: