MEDICARE: VIVIAN A MARINELLI PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	2026-057	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639266927
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIVIAN A MARINELLI PSYD

Provider Business Mailing Address
First Line	:	5225 N IRONWOOD LN
Second Line	:
City	:	GLENDALE
State	:	WI
Zip	:	53217-4909
Country	:	US
Telephone Number	:	414-962-9156
Fax Number	:	414-962-4356

Provider Business Practice Location Address
First Line	:	5225 N IRONWOOD LN
Second Line	:
City	:	GLENDALE
State	:	WI
Zip	:	53217-4909
Country	:	US
Telephone Number	:	414-962-9156
Fax Number	:	414-962-4356

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2006
Last Update Date	:	07/08/2007

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Directions to “ VIVIAN A MARINELLI PSYD” Practice Location

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