Provider Demographics
NPI:1063451623
Name:MARINO, ANTHONY MICHAEL (LICSW)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:MICHAEL
Last Name:MARINO
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 PARK AVE
Mailing Address - Street 2:STE 105
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-3227
Mailing Address - Country:US
Mailing Address - Phone:401-944-9659
Mailing Address - Fax:401-944-9859
Practice Address - Street 1:1020 PARK AVE
Practice Address - Street 2:STE 105
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02910-3227
Practice Address - Country:US
Practice Address - Phone:401-944-9659
Practice Address - Fax:401-944-9859
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW002901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI406568OtherBLUE CHIP
RIAM01505Medicaid
RI3369-7OtherBLUE CROSS
RI62-46448OtherUNITED BEHAVIORAL HEALTH
RI406568OtherBLUE CHIP