Provider Demographics
NPI:1043238785
Name:MARRA, CHRISTINE (PHD)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:MARRA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 JADE ST
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11769-2425
Mailing Address - Country:US
Mailing Address - Phone:631-974-0522
Mailing Address - Fax:
Practice Address - Street 1:358 VETERANS MEMORIAL HWY STE 9
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-4326
Practice Address - Country:US
Practice Address - Phone:631-974-0522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014506-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02145191Medicaid
NYJ400083131Medicare PIN