Provider Demographics
NPI:1184005712
Name:MARCINOWSKI, MICHAEL BLAISE (MA, LCMHC, NCC, CCTP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BLAISE
Last Name:MARCINOWSKI
Suffix:
Gender:M
Credentials:MA, LCMHC, NCC, CCTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8406 SIX FORKS RD STE 104
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-3075
Mailing Address - Country:US
Mailing Address - Phone:617-379-0496
Mailing Address - Fax:
Practice Address - Street 1:8406 SIX FORKS RD STE 104
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-3075
Practice Address - Country:US
Practice Address - Phone:973-800-2817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-09
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11625101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health