=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811313919
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FONTHILL BEHAVIORAL HEALTH, LLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2014
-----------------------------------------------------
Last Update Date | 03/13/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1101 17TH ST NW #530
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20036-4704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-271-1727
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1101 17TH ST NW STE 530
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20036-4746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-271-1727
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | DR. JOANNA MARIE MARINO
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 240-271-1727
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 1000770
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------