Healthcare Provider Details

I. General information

NPI: 1336278399
Provider Name (Legal Business Name): MARVIN JERRY FINE PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 NOTT RD
REXFORD NY
12148
US

IV. Provider business mailing address

70 NOTT RD
REXFORD NY
12148
US

V. Phone/Fax

Practice location:
  • Phone: 518-783-1051
  • Fax: 518-783-1051
Mailing address:
  • Phone: 518-783-1051
  • Fax: 518-783-1051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number010014
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number5732755
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: