=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679192868
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIELLE TORRES
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2020
-----------------------------------------------------
Last Update Date | 07/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18 OLD ETNA RD
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03766-1937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-650-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 NICOLLS RD DEPT OF NEUROLOGY HSC T12/020
-----------------------------------------------------
City | STONY BROOK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11794-8121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-444-2599
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 35052
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------