Healthcare Provider Details

I. General information

NPI: 1609238971
Provider Name (Legal Business Name): DENISE MARINO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2016
Last Update Date: 06/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

694 WHARTON BLVD
EXTON PA
19341-1189
US

IV. Provider business mailing address

1003 KIMBERLY LN
DOWNINGTOWN PA
19335-4495
US

V. Phone/Fax

Practice location:
  • Phone: 610-715-2702
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License NumberPT014270L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License NumberPT014270L
License Number StatePA

VIII. Authorized Official

Name: DENISE MARINO
Title or Position: PHYSICAL THERAPIST
Credential: MPT
Phone: 610-269-1955