Healthcare Provider Details

I. General information

NPI: 1760403232
Provider Name (Legal Business Name): JUDITH MARINICH PCC, LICDC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38039 W SPAULDING ST
WILLOUGHBY OH
44094-6110
US

IV. Provider business mailing address

38039 W SPAULDING ST
WILLOUGHBY OH
44094-6110
US

V. Phone/Fax

Practice location:
  • Phone: 440-918-1806
  • Fax: 440-918-1807
Mailing address:
  • Phone: 440-918-1806
  • Fax: 440-918-1807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number981392
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE-0003813
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS-0017842
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: