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General NPI Number Information
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NPI Number | 1184991507
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Entity Type | Organization
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Legal Business Name | DONNA MARINO, PSY.D., LTD
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Dates
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Enumeration Date | 11/30/2011
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Last Update Date | 11/30/2011
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Provider Practice Location Address
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Address Line | 1101 LAKE ST SUITE 310
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City | OAK PARK
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State | IL
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Zip | 60301-1085
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Country | US
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Telephone | 773-882-0373
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Fax | 708-524-8758
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Provider Business Mailing Address
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Address Line | P.O. BOX 613
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City | CHANNAHON
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State | IL
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Zip | 60410-0613
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Country | US
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Telephone | 815-521-1889
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Fax | 815-521-1889
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Authorized Official
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Title or Position | OWNER
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Name | DONNA MARINO
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Credential | PSY.D.
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Telephone | 773-882-0373
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071006816
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License Number State | IL
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