Healthcare Provider Details

I. General information

NPI: 1962772780
Provider Name (Legal Business Name): ERICA L MARINO PH.D. INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ERICA MARINO-BLANCHARD

II. Dates (important events)

Enumeration Date: 01/10/2012
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3017 W CHARLESTON BLVD STE 54
LAS VEGAS NV
89102-1927
US

IV. Provider business mailing address

3017 W CHARLESTON BLVD STE 54
LAS VEGAS NV
89102-1927
US

V. Phone/Fax

Practice location:
  • Phone: 702-637-5198
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberPI039
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPI039
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License NumberPI039
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License NumberPI039
License Number StateNV
# 6
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPI039
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: