Provider Demographics
NPI:1073618609
Name:DEMENECH, MARINA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARINA
Middle Name:
Last Name:DEMENECH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARINA
Other - Middle Name:
Other - Last Name:DEMENECH SANDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:844 E GORHAM ST
Mailing Address - Street 2:APT 1
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-1790
Mailing Address - Country:US
Mailing Address - Phone:646-388-1498
Mailing Address - Fax:
Practice Address - Street 1:406 N PINCKNEY ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-1410
Practice Address - Country:US
Practice Address - Phone:646-388-1498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0716391041C0700X
WI8030-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN309K1Medicare ID - Type UnspecifiedLICENSED CLINICAL SW