Healthcare Provider Details

I. General information

NPI: 1982668570
Provider Name (Legal Business Name): DIANNE MARINO-SUROVCIK PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 W BUTTERNUT RD
HELLERTOWN PA
18055-9712
US

IV. Provider business mailing address

175 W BUTTERNUT RD
HELLERTOWN PA
18055-9712
US

V. Phone/Fax

Practice location:
  • Phone: 484-851-3486
  • Fax:
Mailing address:
  • Phone: 484-851-3486
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS009188L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: