Healthcare Provider Details

I. General information

NPI: 1336391663
Provider Name (Legal Business Name): MARY A MARINO PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY A ANASTASIOW PH.D.

II. Dates (important events)

Enumeration Date: 10/17/2008
Last Update Date: 01/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1133 BROADWAY STE 807
NEW YORK NY
10010-8047
US

IV. Provider business mailing address

1133 BROADWAY STE 807
NEW YORK NY
10010-8047
US

V. Phone/Fax

Practice location:
  • Phone: 917-478-4816
  • Fax: 212-243-3609
Mailing address:
  • Phone: 917-478-4816
  • Fax: 212-243-3609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number06188
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: