MEDICARE: AMY RENEE MARINO LCSW

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	1041C0700X	Clinical Social Worker	55133	TX

General Provider Information

NPI Number	:	1790326494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY RENEE MARINO LCSW

Provider Business Mailing Address
First Line	:	6013 WISTERIA DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80919-4413
Country	:	US
Telephone Number	:	512-632-9687
Fax Number	:

Provider Business Practice Location Address
First Line	:	6013 WISTERIA DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80919-4413
Country	:	US
Telephone Number	:	512-632-9687
Fax Number	:

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

Provider Enumeration Date	:	10/03/2019
Last Update Date	:	02/03/2021

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