Provider Demographics
NPI:1003243866
Name:MARIANI, JOHN MATTHEW (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MATTHEW
Last Name:MARIANI
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-3581
Mailing Address - Country:US
Mailing Address - Phone:860-646-9660
Mailing Address - Fax:860-643-4704
Practice Address - Street 1:200 MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-3581
Practice Address - Country:US
Practice Address - Phone:860-646-9660
Practice Address - Fax:860-643-4704
Is Sole Proprietor?:No
Enumeration Date:2013-10-10
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002569103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical