Provider Demographics
NPI:1134283898
Name:MARINO, DIANE EE (PFP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:EE
Last Name:MARINO
Suffix:
Gender:F
Credentials:PFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21278 E AVENIDA DEL VALLE
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85242-6919
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21278 E AVENIDA DEL VALLE
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85242-6919
Practice Address - Country:US
Practice Address - Phone:480-641-8622
Practice Address - Fax:480-325-0177
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3925101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ720400OtherA5 -THRP FOSTER CARE HOME