Provider Demographics
NPI:1063450419
Name:MARINE, JANICE K (LCSW)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:K
Last Name:MARINE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JANICE
Other - Middle Name:K
Other - Last Name:FOESS MARINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:610 E CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-2578
Mailing Address - Country:US
Mailing Address - Phone:704-660-1020
Mailing Address - Fax:
Practice Address - Street 1:610 E CENTER AVE
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-2578
Practice Address - Country:US
Practice Address - Phone:704-402-1060
Practice Address - Fax:704-406-1065
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0045671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2876371AOtherMEDICARE
NC6106177Medicaid