Healthcare Provider Details

I. General information

NPI: 1043770597
Provider Name (Legal Business Name): MARINA JEAN MICELI LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 GOUGLER AVE
KENT OH
44240-2401
US

IV. Provider business mailing address

143 GOUGLER AVE
KENT OH
44240-2401
US

V. Phone/Fax

Practice location:
  • Phone: 330-677-4124
  • Fax:
Mailing address:
  • Phone: 330-677-4124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE.2203134
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.2203134-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: